13543 APPLICANT TO FI'LL1IN~INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
FJJ I LDI NG PROJECT I DENTI FICATION
PERMIT NUMBER
So LDING I" APPLICATION & PERMIT
ADDRESS
- BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 13543
s OWNERS a+ e PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT` � `FEE"
1 PHONE
COONTERACTOR'S JOUTLETS-SWITCHES-RECEP 10.00/1.00
NAM
to G0 ncf UC.No. LIGHTING FIXTURES' 10.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
' A.D�fD,RnESS C4.
PHONE
PHONE , 1 PANELS 10.00 DATE OF APPLICATION
Rc"ITE
OR - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
O
ENGINEER-
' - uc.No. SIGNS TRANS. 3.00
ooREss ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
w O o- LICENSED CONTRACTORS DECLARATION
er 0 U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
Z 11' (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F Di Professions Code nd�nw.lIcense is in full force f t.
p 0 vi W License Class ✓a J h Lic.Number 1 -
Date-��• /7-JbP'2-Contractor
a m =+ ^-�T- - BUILDING PERMIT "
M IS ea OWNER-BUILDER DECLARATION INFORMATION '
io MISC.- REFER TO ORD '
s ;' v"i I hereby affirm that 1 am exempt from the Contractor's License VALUATION $/FT.
.F u o a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE - 10.00
Cade:Any city or county which requires a permit to construct,alter,
w
a a Q O improve,demolish,or repair any'structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. _
O, requires the applicant for Such permit to file a signed statement that TOTAL PERMIT TO
u w m he is licensed pursuant to the provisions of the Contractor's License
i
Law(Chapter 9(commencingwith Section 7000)ofDivision 3 ofthe <�
4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
0 the basis for the alleged exemption.Any violation of Section 7031.5 7 STORIES TYPE CONSTR.
i` by any applicant for a permit subjects the applicant loaded penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not mom.than five hundred dollars(55001.1:
❑ 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 do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of -
"• property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
/
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). USTRIAL WASTE INTERRES IND CON PS Orhef
IND . 30.00
❑ I,as owner of the property,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 docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractim s)licensed pursuant to / SEWER-SANITARY-STORM EA.200ft/10.0010 -'
the Contractors License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,B.&P.C.for this WATER HEATER W/YEN 6.00 �p ^
reason
Owner Data WATER SYSTEM t 5.00 s ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP Y' 1 Cal 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified '�' ZONING ENG.SITE NO.
copy thereof(Sec.3800,mLab.C.).R/ Q
Policy No. Copany e JA
O '❑ Certified copy is hereby furnish�•,d C, FIRE SPHINK ENERGY T-24
Z 2 ❑ 'Cerli(ied iypy is filed xlitlr fhe cl m e iom division. MISC- REFER TO ORD. ❑ ❑ ❑ ❑
O Applicant ,uLlJ( !7 p Y N Y N
X y / PERMIT ISSUANCE 10.00
LU CERTIFICATE E EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLC.CONTR. LIC.NO. PLG. /41.),
Q� Y❑ rvQ Y ❑ N❑
Cl (This dollars
need not be completed if the permit is for one TOTAL
hundred dollars($100)or less.)
U O I certify that in the performance of the work for which this per- Qlwf. MECHANICAL PERMIT FEE FEE SUMMARY
U. mit Is Issued,1 Shall not employ any person Wary manner s0 as t0
OW become subject to the Workers'Compensation Laws oGCalifornia.
D. Date Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emption,you should become subject to the Workers'Compensation APPLIANCE - 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C.)
such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE'
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this.permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name -
Lender's AddrHEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
ess
I.certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
informationis correct.I agree to comply with all city and county PLUMBING Q w
ordinances and state.laws relating.to building construction,'and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000BTU)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 PERMIT ISSUANCE 10.001CONST.TAX
may in any way accrue_agaixst said City in consequence of the
granting of this permit. MECH.CONT. LIC.NO. TOTAL
/7� qg TOTAL
Signature of Applicant/ ntractor - ate '
OFFICE COPY -