14063 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT. PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIr NUMBER
BUILDING 10 3 APPLICATION & PERMIT 14063
ADDRESS
//(�gO G A� L�,.� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
. NAME •• �y QTY. ELECTRIC PERMIT FEE
..
:e'-JW 'y �i�P./] r. 'PHONE
CONTRACTORS
NAME �!- O UTLETS-SWITCHES-RECEP 10.00/1.00
-53
Sra Cir uc.rvo. SUL70 Z ILIGHTING FIXTURES ' 10.00/1.00 ,A-
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
(4 ✓�/✓f� ✓� A(1 PHONE ,a7-/�7 Z PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELSIOVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
on
ENGINEER
LIC.NO. ISIGNS TRANS. 3.00
AR. ENG. - - SPECIAL CIRCUIT 5,06 PERMIT VALIDATION
ADDRESS
BS
ZIP EMP.METER OR POLE INS. 20.00 �s
APPLICANTS MOTORS SEE FEE SCH- a
ADDRESS
SERVICE CHANGE .�n- 1 20.00 a
woo LICENSED CONTRACTORS DECLARATION
¢
u u I hereby affirm that I am licensed under provisions of Chapter 9 •1r`"/ ISSUANCE DATE.
Q w (Commencing with Section 7000)Of Division 3 of the Business and ! I ~ - BLDG. ELECT. PLG. MECH.
H y Z Professions Cole,and 19 vJicena,is in full force andel ,t / x ❑ ❑ O
Z o u - License Class G VV Lic.Number " `� A,
2 in f ° Uate ` Contractor C$ CLI"dI l l
F J �•♦•, 1
¢ Be ez t• BUILDING PERMIT
IF Be w¢ OWNER-BUILDER DECLARATION INFORMATION
oA° MISC.- REFER TO ORD
K
; LL F 1 hereby affirm it I am exempt from Om Contractor's License VALUATION
FUN Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requlresa permit to construct,alter,
¢ ¢Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. _
0 oOo u requires the applicant for such permit to e a signed statement that a TOTAL
W 9 y he IS licensed pursuant to the provisions of the Contractors License /�M �//� / a�� PERMIT TO
File
Hi >
Law(Chapter 9(commencing with Section 7000)ofDivision Softhe �C.LIrT
¢ Business and Professions Code)or that he is exempt therefrom and DTV.. PLUMBING PERMIT FEE
le=$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A. by any applicant for a permit subjects the applicant oacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages asBACK FLOW PROTECT.DEVICE 4.00 UCC.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 IFIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself Or through his own employees,provided that such noprove.
meats are not intended or offered for sale.If,however,the building IGAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have Ole burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). JINDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors.lo construct the project(Sec. 7044,Business ILAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10,00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.L
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
D Applicant - - Y❑ N❑ Y ❑ N❑
� y PERMIT ISSUANCE 10.00 FLOOD ZONE A.LU.C.
LU - CERTIFICATE OF EXEMPTION FROM WORKERS' '
W > COMPENSATION INSURANCE PLG.coNrH. LIC.No. PLG,
CL Q (This section need not be completed if the permit is for one TOTAL Y❑ ❑N v ❑ N❑
D Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL FF mit is issue I shall not employ anv person in an sa. ser so as to _
O W beco e u c the Workers'C a sa ton L' o� a' yV BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} to NOTICE O PLICANT: If,afWmaki.g lbil Certificate of Ex-
? emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with FEE
V such provisions or this permit Shall be deemed revoked. AIR HANDLING UNIT(TO 10AOOC.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of1the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.CJ.
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC 06-
Lender's Address-
1 certify Ihat I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over ID0,0000TU)SEE FEESCH. 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 B aiBit said City in consequence of the PERMIT ISSUANCE 10.00
gmntin flhIS permit / MECH.CONT. LIG NO. MECH.
(,fcc ✓f C ib l9 �f TOTAL TOTAL
Signa eof Applicant/Contractor Da[
OFFICE COPY