13579 4,f APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
_BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BuNo . APPLICATION & PERMIT 13579
ADDRESS
6 C S' S MZ BUILDING
-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'a PLAN CHECK VALIDATION
NAME DTV. ELECTRIC PERMIT FEE
PHONE
NT ACTORS
/ NAE ` 11 OUTLETS-SWITCHES-RECEP 10.00/1.00 -
5.CQIU kic LIC.NO.c - 167 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'ErAPPLIANCES-RESIDENTIAL 4.00 00T
ADDRESS
SI/ lumrmE a ^ 1 PANELS 0.0 Q DATE OF APPLICATION
ORRCHITECT PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 6,00 PERMIT VALIDATION
ZIP EMP.METER OR PPE INS. 20,00
APPLICANT'S MOTORS L&-gSEE FEE SCH.
ADDRESS
SERVICE CHANGE„ ,. _ 20.00 y�
Dai a.V L3 N V 1:_
,02 LICENSED CONTRACTORS DECLARATION
a u U 1 hereby affirm that I am licensed under provisions of Chapter 9 �,a ISSUANCE DATE
<i (commencing with Section 7000)of Division 3 of the Business and yaAJ. VI b BLDG.' ELECT. PLG. MECH.
z�
D. Professions Code,and my license is in full f-' FQ "QJI grfEC{.k 9 ❑ ❑ - ❑
O Z H, License Class O Lic.Number
Dale Contractor
¢ x f BUILDING PERMIT
¢ 0 w u OWNER-BUILDER DECLARATION
o a MISC.- REFER TO ORD INFORMATION
E
;0 I hereby affirm that I ng s n exempt from the Contractor's License VALUATION $/FT.
F u o j Law forAnythe
county Owhi h requires a permit woodtmci.aions PERMIT ISSUANCE 10.00 O --
Code:Any city or for n pair any structur e permit o its issuance,
iter,
It¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC:NO. EC. /l`0
i 0,
requires the applicant for such permit to file a signed statement(list a e o� E /' TOTAL/ PERMIT TO
E
$ he is licensed pursuant to the provisions of the Contractor's License �L r
i Law(Chaplet 9(commencing with Section 7000)of Division 3 oflht
- ¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ = $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(S500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ 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 Pmfessiotn 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 FIXTURES
himself
TRAP S.OD SO.FT.ELOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve GA$-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.) ZOO - BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omar
prove for purpose of sale). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ I,as owner of the property,am exclusively contracting with
licensed contractors m 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
contracts ct Stith cprojects with a CnnlraClOr(5)II[¢n5L'd pnRllan[t0 SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO, PARCEL NO.
(lie tracts or such
h Law.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK I!RS'COMPENSATIgN DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm Ihat 1 Ja ,, q-r& ate of consent to sel0.insure, ZONING
ora certificate of W re`1l C_dd Pensalion Insumnee,or a cerli0ed ENG.SITE NO.
Copy thereof na Co Lah.y e'!
Policy No.Una Company J+
O ❑ Certified copy is hereby(umislud. FIRE SPRINK ENERGY TR4
Z Z _'y•Certifie Copy s filed Th the city inspection division. MISC- .REFER TO ORD.
Q Ale,lent _C'71 C r Y❑ N❑ Y ❑ No
X -y PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UC.
Lu Cb:R7TFICCOI OP EXEMPTION FROM WORKERS'
W _ COMPENSATION he cON INSURA NCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
1 0 (This action nreJ not he completed if the permit is for one TOTAL
::) Z hundred dollars($1001 or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
Ig.. t7 mit is issued,1 shall not employ any person In any rmnner so as to
U become subject to the Workers Compensation Laws of California. BUILDING
O i Dale Applicant ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: If,after making this Certificate of lix-
I- 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 IOAOOCF.M.) 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
Lendeis Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC rO
Lender's Address x�
I certify that l have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is Correct. I 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
It are by authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH.1 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 consequence of the PERMIT ISSUANCE 10.00
granting ofit rmil. MECH.CONT. LIC.NO. MECH.
11� TOTAL TOTAL
Sign are pbcmd omrxctor Date
OFFICE COPY