13146 !(PFrLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUIL-OI NG P90JECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 1314 6
ADOREss
Lo L G k, S BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
• NAME TV. ELECTRIC PERMIT FEE
Z%0/ K#Sm#-XreArPXONE/JLJ
CONTRACTOR ^
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
W&Sr- LIC.No.44
JrI] ILIGHTING FIXTURES 10.00/1,00
C,ONTRACTOR'S L� PPLIANCES-RESIDENTIAL 4.00
AD(j/LRE65 y /`/''
D _ oh_A-- bIQ, PHONE fJ u' PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00 '
ARCH.
OR ENG SPECIALCIRCUIT 5.00 PERMIT VA LI DATION
ADDRESS
zap EMP.METER OR POLE INS. 20.00
ADDDRESSDRESS
AMOTORS SEE FEE SCH. --Qr-�
SERVICECHANGE PAID 20.00
w o o LICENSED CONTRACTORS DECLARATION
<u v 1 hereby affirm that I am licensed under provisions of Chapter 9 (k V J / ISSUANCE DE
z w (commencing with Section 7000)of Division 3 of the Business and A, BLDG. ELECT. PLG. MEC..
Ni Professions Code,SEAMY license is in full torce,ap e-fLfr,�t6 ❑ ❑
O Z w o License Class Lic.Number �l �I L (supe In
DFff-
ate Comraclor •7 ul V P
a'r E C) BUILDING PERMIT
¢ m ¢ ¢ OWNER-BUILDER DECLAR N INFORMATION
o T u_ REFER TO ORD
K
r.w 1- I hereby affirm that I am exempt from the Contractor's License MISC.- VALUATION $/FT.
F u.y J Law for the following mason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 ,Q-
Code:Any city Or county which requires a permit to construct,alter,
Q Q ¢ Improve,demolish,Or repair any structure,prior to its Issuance,also ELEC.CONTR. LIC.NO. ELEC. 99
O LL requires the applicant for such permit to file a signed statement that TOTAL UPERMIT TO
w $ w he is licensed pursuant to the provisions of the Contractor's License - Lq
F i > Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the T(sM !6 Le
q c Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
ts:F-$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penally ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(8500).):
❑ 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 ar 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 dues suds work F IXTUR ES-PER TRAP 5.1111 SO,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improv, GAS-EA.SVSTEM-11NC.40UTlETS 6,00
mems 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 Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. - 30.00 ❑ ❑ C-1 ❑ 1:1❑ 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 not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
oontmets 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.
❑ Iamexemptonder Sec. ,B.&P.C.forihis WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILENO.
WORKERS•COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsenl to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.CJ�
Policy N rt Company -
Q ❑ 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. v N v N
Q Applicant ❑ ❑ ❑ ❑
~ va PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
ul - CERTIFICATE PE EXEMPTION FROM WORKERS'
IJJ >_ ,COMPENSATION INSURANCE. � PLG.coNTR. LIC.no. PLG.
1 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z hundred dollars IS 100)or less.)
L) 0 1 certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I. mit is issued,I shall not employ any person in any manner so as to
OW become subject to the Workers Compensation Laws of California. BUILDING
Date Applicant ALTER 08 ADD TO MECH. 5.00
>_ US NOTICE TO APPLICANT', If,after making this Certificate of Ex-
)... Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply witM
h 'FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F. .) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OV 10MC.FM.) 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. MICROFILM
3097,Civ.C.). , HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's No HEATING UN IT(OVER 100,000 B.T.U.)9.50 - ELECTRIC 311 u
Lender's Address
. I certify that I have read this application and state that tim above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 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 the1301 LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly 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 wa accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting of er it. MECH.CONT. LIC.N0, MECH.
TOTAL TOTAL
igna reof Applic nlraclor Dale
OFFICE COPY