13496 31CANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
UI LDING PROJECT IDENTIFICATIONPERMIT NUMBER
BUILDING APPLICATION & PERMIT 13496
ADDRESS, / 5 n/vs BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME OTV, ELECTRIC PERMIT FEE
PHONE
NA.ER"C a UTLETS-SWITCHES-RECEP 10.00/1.00
Ita U A La..N . _17/"697 LIGHTING FIXTURES 10.00/1.00
ro TRACTOR'S - PPLIANCES-RESIDENTIAL 4.00
ADDRESS /�
176 n- , .ePHONE �3�710130 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.08 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 _ )
ADDRESS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 Si/7(/8- -/r
woo LICENSED CONTRACTORS DECLARATION
rt u U 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
vHi a$ (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H Professions Code en y license is in full fort and
se C is L a t. ❑ El ❑
z o= LicenLic.Number pq
9 r Dale Contractor
a y f Yj
BUILDING PERMIT
¢ is OWNER-BUILDER DECLARATION INFORMATION
a'xIS. I- I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
LLo¢ Law for the following reason.(Sec.7031.5,Business Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city orcounty which requires a permit to construct,alter,
ac 2 Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC.
O¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A. m$ he is licensed pursuant to the provisions of the Contractors Licensepp
F Z> Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe �Lip
�
2 i o Business and Professions Code)or that Ise is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ H the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
i ; 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 dollars($500).):
❑ 1,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 2 DRAINS-FLOOR,ROOF,AR EA,COND. 5.00/0 —
Code:
.00 Q —Code:The Contractor's License Law does not apply to an owner of
property who builds orimproves thereon,and who does such work FIXTURES-PER TRAP SAO — SO.FT.FLOOR AREA TOTAL ACREAGE
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 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON PB Otbar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00d
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 VB. 0 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-OVE BIP, 1,00
contracts for such projects with a contractor(s)licensed pursuant to .,200it 1_0.00
the Contractors License Law. SEWER-SANITARY-STORM EA ) TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec.—,B&P.C.for this WATER HEATER W/V IJ , 6.00
reason
Owner Date WATER SYSTEM ,q
n 4<IG ACC.DATE ACC.FILE NO,
WORKERS'COMPF.NSATION DECLARATION WATER TREATING EQU(Y.tj 5.00
I hereby affirm that I have a certificate ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(S c.3 ODS,�ab.CJ, -
Policy No 4m any l !J6
0 ❑ Certified Cop is he re by fufnlsIt d. FIRESPRINK ENERGY T-24
Z Z ❑ Certified is file '1 city inspection division.
O pplicant MISC.- REFER TO ORD. Y� N Y � N�
rn PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU CERTIFICC PE EXEMPTION PROM WORKERS'
fL _ COMPENSATION INSURANCE FILE,CONTE. LIC.NO. PLG. 74
IL 0 (This section need not be completed if the permit is for one TOTAL Y� NO Y � N�
7) Z hundred dollars($100)or less.)
U O I certify that in the performance of the work for which this per. DTV. MECHANICAL PERMIT FEE FEE SUMMARY
U. I— mil is issued, I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>. w 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 with FEE
U 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 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction loading 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 Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
1 eerily that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4,01) -�
information is correct. I agree to comply with all city and county PLUMBING S _
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
I hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,0008TU)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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting DON permit. x MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature aIand/Contractor Date
OFFICE COPY