13545 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
.i- BUI LDINd PROJECT IDENTIFICATION Zakr
- - PERMIT NUMBER
aUf D1"G .a,
a'DRESS APPLICATION & PERMIT 13545
- BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
5'' r
&_.'s PLAN CHECK VALIDATION
• "AME QTY. ELECTRIC PERMIT FEE
;CilPHONE
CONTRACTOR
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
rLIGHTING FIXTURES 10.00/1.00
s LICE No.
co T CTOR's PPLIANCES-RESIDENTIAL 4.00
ADDRESS
p6 �-� o� _ PANELS 1D.DD DATE OF APPLICATION
ARCHITE PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C:NO.
OR
ENGINEER
LIC.No. SIGNS TRANS, 3.00
ADDRESS ENC. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00 ^
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
00
0
0 o LICENSED CONTRACTORS DECLARATION
U u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m< to (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MEC".
H o i Professions CoJ yk is in full fore effe 1. ❑ ❑ O
O z o License lass Lic.Number G
Dale Contractor
a Y f BUILDING PERMIT
E a w u y OWNER-BUILDER DECLARATION INFORMATION
wLL 1 hereby affirm that 1 am exempt from the Contractor's Lieense MISC.- REFER TO ORD
r t- o < Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION
at Cade:Any city or county which requires a permit to construct,alter, -
a, 2 Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG.NO. ELEC.
C u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
K$ he is licensed pursuant to the provisions of the Contractor's License L�G
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
H D the basis for the alleged exemption:Any violation of Section 7031.5 STORIES TYPE CONSTR.
i;$ by any applicant for a permit subjects the applicant to a civil penalty
ofnot more than five hundred dollars(S500).):
ALTER-DRAIN -WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will Jo the work,and the structure is not .
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 v SD.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve GAS-EA.SVSTEM-1 INC.4 OUTLETS 6.00
amts are not intended or offered for sale.If,however,the building /
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omar
prove for purpose of sale.). INDUSTRIALWASTE INTER. 30.00
❑ I,as owner of the properly,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does nor apply
to an owner of property who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with u contractors)licensed pursuant to /
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT N0. PARCEL NO.
❑ lam exempt under Sec.-,BARC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM5.00 V ACC.DATE ACC,FILE N0,
WORKERS'COMPf NSAT10N DECLARATION WATER TREATING E I 5,00
I hereby affirm that I have a certificate of consent to self-insure, r' '1-Z I ZONING ENG.SITE NO.
or a certificate a(Workers'Compen ran Insurance,or a certified
copy thereof(Sec.,3800,Lab.C.). �s•1{ RUV
-
Policy No. COMES., IIV
yGJ"
O ❑ Certified copy is hereby fu nished. e FIRE SPR INK ENERGY T 24
Z Z ❑ Certify p is filed',
iled ,,�1 the Cil Is ecti division. y N� Y N[]
0 Applicant O MISC.- FER TO ORD.
fL H CERTIFICATE:Of EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 d FLOOD ZONE A.L.U.C.
LU >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 O .(This section need not be completed if Ilia permit is for one TOTALO Y[] NE] Y 0 NC]
Z It unfired dollars IS IOD)or less.)
U O 1 certify that in the performance of the work for which this perDTV. MECHANICAL PERMIT FEE FEE SUMMARY
IJ_ H mit is issued,1 shall not employ any person in any manner SD as to
U become subject to the WmIcroi Compensation Laws of California. BUILDING
0 y Date Applicant ALTER OR ADD TO MECH. 5.00
>_ N NOTICE TO APPLICANT'. If,after making this Certificate of Ex..
emption,you should become subject to the Workeri Compensation APPLIANCE - 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with FEE
C.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10)=CF.M.) 6.00 SEISMIC FEE
1 hereby affirm that (bete is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT(OV ER 100,000 B.T.U.)9.50 - ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 �a (.1/
information is correct. 1 agree to comply with all city and county BOILER-COMPI3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING Vp�
ordinances and stale laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above.mentioned property for inspection purposes,
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue ggainst said in consequence of the PERMIT ISSUANCE 10.00
gran of this permi MECH.CONT. LIC.NO. MECH.
L TOTAL TOTAL
Signature ofApplicant/Copdactor
OFFICE COPY