13270 Ar'LICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION APPLICATION
N & PERMIT PERMIT NUMBER
Bonn,
. ,ao98 �s c+
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 13270
ONNER'B PLAN CHECK VALIDATION
NAME DTY- ELECTRIC PERMIT FEE
vHOn -3
CONTRACTORS.
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
l44 -Re I LIC.No.31� 6 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR 5 C;A PPLIANCES-RESIDENTIAL 4.00
ADDRESS1^V �'T
`-H 1 �r /PHONE - PANELS 10.00 GATE OF APPLICATION
ARCHITECTon PLAN(OVER 200 AMP) 20.00 PLAN CHECK FEE P,C.NO.
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
ADDRESS eea SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 �7
ASS
ADDRESS MOTORS SEE FEE SCH. /)� '♦
-
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION 4,f 7
a i w 1 hereby affirm that I an licensed under provisions of Chapter 9 ISSUANCE DATE
Q (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F o i Nufessions Cud ud my license u in full fort nd e feet. ❑ ❑ ❑
o i 2 W License Lic.Numh
m�
Date y Contractor
a x J BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DE RATION
¢ u,u INFORMATION
X
A vs 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
Asa Law for the followingmascn.(Sec.7031.5,Busmessand Professions PERMIT ISSUANCE VALUATION f/FT.
y y Code:Any City or county which requires permit to construct,alter, ELEC.CONTR. LIC.N0. 10 DD
¢ a;0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.
O¢ requires the applicant for such permit to file to signed statement that TOTAL PERMITTO
a,w he is(Chapter
pursuant to the provisions of the Contractor's License ' /rL
the
5 40 Law(Cha nd Profession,
Code)or Section is 00)exempt
therefionrom
o and
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
zio
¢ H the baso for the alleged exemption Any violation of Section 7031.5malty STORIES TYPE CONSTR.
A � by any more
fora permit subjects the applicant loacivil penally ALTER-DRAIN -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
their sole compensation,will do the work,and the structure is not Ca Roue RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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-PER TRAP 5.00 SO FT.FLOOR AREA TOTAL ACREAGE
himself or fl rough his own employes,provided that such improve-
ments art not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or Im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Ome,
❑ I,as owner of the property,on exclusively contracting with ❑ ❑ 1:1 E]
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 Contractors License Law don 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 contractor(s)licensed pursuant to
the Contractor's Licence law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,tl.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have acertilicateofconsent toself-insum,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.I
Policy No `��. cimpanyR ,I AI �hS
O g, Cerhfe5J copy a hereby fumishedT-
Z 2 ❑ Certifiry copy, ¢ GIeJ *kh Ilre city inspection dlvisi0n. FI RE SPRINK ENERGY T 20
FO Applicant sa.rY'�/ � MISC.- REFER TO ORD. y� N� Y ❑ N[:]
K N CITIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
UJ �_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PTOTAL V NLG.
1 ❑ ❑ ❑ ❑
O (This section need not be completed if the permit is for one - v N
Z) 2 hundred dollars(5100)m less
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not employ any person in any manner so as to
Q W become subject to the Workers'Compensation Laws of California.
Do¢ A Imam BUILDING
} N NOTICE. TO APPLICANT: If,afic,making this Certificate of fix- ALTER OR ADL] '9ECH.�� 5.00
F 2 emption,you should become subject to the Workers'Com pe mat ion APPLIANCE �'
provisions of the Labor Code, you must forthwith comply with 5.00 PLAN CHECK
V such provisions or this perinit shall be deemed revoked. AIR HANDLING UNIT(TO.105C(F. ) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING L) ff.(OV 160ODC.EM-) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (W TH DUCT) 5.00 S. LO,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 -p V
Lender's Name H EATI NG U N IT(O V ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
0 1 certify that I have reed this application and slate that the above � VENTILATION FAN (SINGLE) 4.00 $_p Q
information is correct. I agree to comply with all city and county. PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3H.P.or1DO,DOOB.T.U.) 6.00
hereby eptined roprrtyfor ins of thu city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
mcnlioned property for impaction purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs end expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the .00
9.5#hg Of this permit- / ------r11 MECH.CONT. LIC.NO. MECH.
-i -?_3-7 - TOTAL ib TOTAL
iplature of Applicant/Con etor Date (l '3 `w
OFFICE COPY