13161 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
:•) �BWPERMIT NUMBER
LDINGPROJECT IDENTIFICATION APPLICATION & PERMIT -
"° 13161
.y DOREss BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
Lp
OWNER'S PLAN CHECK VALIDATION
"AME Z S S 3 ATY. ELECTRIC PERMIT FEE
Zqw d SkANONE
NAMERwcTORs UTLETS-SWITCHES-RECEP 10.00/1.00
Let&-A klc,No ILIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S �(.Ga, PPLIANCES-RESIDENTIAL 4.00
ADDRESS
h PHONE ITCZU PANELS 10.00 DATE OF APPLICATION
ORCHI ECTPANELS (OVER 200 AMP) 20.00
PLAN CNECK FEE P.C.NO.
OR
ENGINEER
Llc.NO. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.0 Q •'-
APPLICANT'S MOTORS S$@ H. \
ADDRESS �
SERVICE CHANGE 20.00 .,
Doo LICENSED CONTRACTORS DECLARATION I 1 �S
/6p/
U w I hereby affirm that I am licensed under provisions of Chapter 9 { 155 CErOATE
(commencing with Section 7000)of Division 3 of the Business and QI Upe BLDG. ELECT. PLG. MECH.
w'^ Professions Code.an y license is in full fore yy�d c[feCl 1 Y -❑ ❑ ❑ ❑
i o y License Class Lie.Number �I Y ` -6s
C mj Dale CoNmctor
a ae s - // BUILDING PERMIT
m w ` OWNER-BUILDER DECLARAT INFORMATION
a o a 'MISC.- REFER TO ORD
w ; y I hereby affirm that I am exempt from the Contractor s License i VALUATION $/FT.
�u.0 J Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Mas Code:Any city or county which requiresa permit Io CmnStruCI,alter,
5 ¢ ¢Q improve,demolish,or repair any onicture,prior to its issuance,also ELEC.DONTR. LIC.NO. ELEC. 2a
n a DLL requires the applicant for such permit to file a signed statement that TOTAL 3 PERMIT TO
w$w he is licensed pursuant to the provisions of the Contractor's License
ri> La..(Chapter 9(commencingwilh Section 7000)of Division 3 ofthe /GN J1z 6
s z o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE r -
le H B the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permitsubjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 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 docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
�T meats are not intended or offered for sale.IL 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 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct [lie 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
contracts for such projects with a contractons).licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCELNO.
❑ lamexemptunder Sec. ,B.&P.C.I'or this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ALC.FILE NO.
WORK F-RS'COMPENSAT ION DECLARATION WATER TREATING EOUIP. 5.00
I hereby,affirm that I have a certificate of consent to sell'-insure, TONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
Policy No.of(Sec.3800 Lab C Co piny ) •S 4 % F',1wd
O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z ❑ Certified DO 's 'led wy 0 e ection division. MISC.- REFER TO ORD.
Applicant �. Y❑ N❑ Y ❑ N❑
Hy
CERTIFICATE FICATIi 01;-OPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
�
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG. V❑ N❑ Y❑ N❑
M. O (This action need not be completed if the permit is for one TOTAL
D Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
1... ? 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,OODC.F.VA0 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.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 of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name
Lenders Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and slate 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 601 LER-COMP lover 100.000 BTUI SEE FEE SCM. 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.against Said City in co equence of the PERMIT ISSUANCE 10,00
gmntingofth emit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Si u f Applicant/ acf6r, 'Date
OFFICE COPY