13296 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
S.hLmaNNSG: APPLICATION & PERMIT
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 13296
WNER'a PLAN CHECK VALIDATION
"AME CITY. ELECTRIC PERMIT FEE
CN \ _'1`PHONE
c N aAcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
AME
LIGHTING FIXTURES 10.00/1.00
oNT AcroR's [APPLIANCES-RESIDENTIAL 4.00
Fo REss
PH NE PANELS 10.00 DATE OF APPLICATION
AGRCHITEC PANELS (OVER 200 AMP) - 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC Nor SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT $,00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT 5 MOTORS SEE FEE SCR.
ADDRESS
Q J /I
SERVICE CHANGE 20.00
w
00 LICENSED CONTRACTORS DECLARATION ``J1 7
a u o I hereby affirm that 1 am licensed under provisions of Chapter 9 � ISSUA TE
y 4 OOrr (commencing with Section 7000)of Division 3 of the Business and - BLDG. [[Eyy{555CO ut LG. MECH.
H w Professions C e,and my license Is In full fore and effe L 0 ❑ ❑
,e o H - License Class_(_
Lie,Numbed �_ u
2.
r w Datc Contractor-wyp.
¢ m s ION BUILDING PERMIT
¢ 0 w ¢ OWNER BUILDER DECLARATION INFORMATION
O ca MISC.- REFER TO ORD
F.
3 n H 1 hereby collo that I am exempt from the Contractor's License VALUATION S/FT.
Huo`� Law for the followingreason.(Sec.7iresa per
Riocnd Professions PERMIT ISSUANCE 10.00
Code:Any mulish county whiny reqstructure,
,prior
Rio also
S rt Q 0 improve,demolish,or repair any almelure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
LL requires the applicant for such permit to file a signed Statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
LaLaw9(commencing with Section 7000)of Division 3 ofthe ��/s"L�L(.f/(Y'
Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢ $ the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
A. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 '
of not more than five hundred doll..($500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
0 property who builds or improves thereon,and who does such work FIXTURES,PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve GAS-EA.SV$TEM-1 8.00
mems are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-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
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors tD 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 properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.1 1.00
C
ontracts for such projects with.contractors)licensed pursuant to SEWER-SAN ITAR V-STORM EA.200ft/10.00
the Contradoi s License Law. TRACT NO, PARCEL NO.
❑ I am exempt under Sec..,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Cn ncr Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to.11-fi sure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof( cc.3800,LAC.) 11
Policy No. Company���� L7��'
0 ❑ Cerlil)edcopyishereby9rrnished. FIRE SPRINK 'ENERGY T-24
Z Z ❑ Certi i co is B d �jB tIL,��ILy�inspection division. MISC.- REFER TO ORD. � � F]
O App lican `- 'stl V N V N
I"' yPERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
CERTIFICATE OF EXEMPTION FROM WORKERS'
UJ _ COMPENSATION INSURANCE: PLG.CONTR.' LIC.NO. PLG. Y� N� Y[:] NC3
EL O (This section need not be completed if the permit is for one TOTAL
0 Z hundred dollars IS 100)or less.)
L) O 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
O W become subject to the Workers Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} y 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 Use Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=r-F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perforrai of the work for which this permit is issued(See. MICROFILM
3097,CR.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UN IT(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
information is correct.1 agree to comply with all city and county PLUMBING
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 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned pr Perry for inspection purposes.
(We) .gree to ve, indemnify .nd keep humlless the City of MISC.- REFER TO ORD.
Cupertino against iabili in judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may i y a way accrue a Bar said City in consequence of the
B< ( 1 ma. MECH.CONT. LIC.NO. MECH. r
TOTAL TOTAL J
1 a are.r pp an/Contractor Data
OFFICE COPY