13235 Lv r A^PLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT[FICATION - PERMIT NUMBER
°,N,a APPLICATION & PERMIT
,_pF.1 F13235
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
UoNER'S PLAN CHECK VALIDATION
" E P QTY. ELECTRIC PERMIT FEE
PRONE
Co TRACTOR'S UTLETS-SWITCHES-PIECED 10.00/1.00
L 1 (e- LIc.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
IS 'EPRONE ,3 - ' 7 PANELS 10.00 DATE OF APPLICATION
ORRCRITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEEP.C.NO.
ENGINEER
LIC.No. ISIGNS TRANS. 3.00
ARCH.OR
ENG SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP - EMP.METER OR POLE INS. 20.00 ,S
APPU CANT'SCK
ADDRESS MOTORS SEE FEE SCH,
SERVICE CHANGE 20.00
o O LICENSED CONTRACTORS DECLARATION
a it u I hereby affirm that I am licensed under Provisimn of Chapter 9 ISBUAAANNNCE DATE
(commencing with Section 7000)of Division 3 of the Business and _ BLDG. ELECT., PLG. MECH.
r v,z Professions Code su Y license
is in full for 'FZ ❑ El El z a y - License Class Lic.Number
r Date Contractor--F)-
a sz s BUILDING PERMIT
¢ ¢ OWNER-BUILDER DECLARATION '
A a a S INFORMATION
a, 3 LL H I hereby affirm that I am exempt from the Contra for's License MISC.- REFER TO ORD
HLLOg Law for the following mason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 1000 VALUATION S/FT.
Code:Any city or county which requiresa permit to construct,alteq
rt rt Q 40 improve,demolish,or repair any structure,prior to its Issuance,also ELEC.CONTE. LIC.NO. ELEC.
O¢ requites the applicant for such permit to file a Signed statement that TOTAL PERMIT TO
w$ he Is licensed pursuant to the provisions of the Commelor's License Q
FiQ Leco
w(Chapter 9( mmencing with Section 7000)of Division 3 ofthe T U
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ F¢-$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A3 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
0 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCL.GROUP RES.UNITS
their min compensation,will do the work.and the structure is not
intended or offered for sale(Sec. 7014, Business and Professions DRAINS-FLODR,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-PER TRAP 5.00 sa FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
merits amnot intended oroffered for Sale.IL however.the building I GAS-EA.SYSTENI.1 N.00OUTLETS 6.00
or unprovemem is sold within one year of completion, the owner- GAS-EA.SYSTEM-'OVER 4 (EA 2.00
builder will have the hurden of proving that he did not build or im- BUILDING USE
prove for purpose ofsaleJ. INDUSTRIAL WAST INTER`SI 30.00 RES IND CON PB Omer .
❑ I,as owner of the property,am exclusively contracting with _ - 0 ❑ ❑ 1-1 El
licensed contactors to construct the Project(Sec 7044,Business LAWN SPRINKLERS--1 INC.5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor i License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS- R� .) 1.00
contracts for such projects with a umtractons)licensed pursuant in
the Contraemr's License Law. SEWER-SAN ITA- -S ORM EA.200ft/10.00 �- TRACT NO, PARCEL NO.
❑ 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 ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby at firm that I have a certificate of consent to self-insure, ZONING
or a eerlificam of Workers'Compensation In...gnce,or a certified ENG.SITE NO.
copy thereppff e . Lab.Clle 1ue�._
Policy NOY- pant
0 ❑ Certified copy is hereby famished.
Z Z Cemifyni c. y i1,flle ith the pecy'r'n drvlsion. FIRE SPRINK ENERGYT]a
FO Adplicant Oh13_ t, L3` b (�Q__ MISC.- REFER TO ORD. y0 N❑ Y N�
N' CF.RTIFICA'I E OFEKRMPI'ION FROM WORKERS' PERMIT ISSUANCE 10.00 Id FLOODZONE A.L.u6,
LU 1 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. el V� N� V �
EL Q (This section need not he completed if the Re nn it is for one TOTAL N
Z) Z hundred dollars IS 100)or less)
U 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 becomesubject to the Worker Companmtion Lawsof California.
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
}
06 NOl'ICE TO APPLICANT: If.after making this Certificate of Ex-
Sorption.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=11F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVEA 10=C.F.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 fSee. MICROFILM
3097,Civ.C.L - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
• 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 mlm y PLUMBING qq d'li
ordinances and state laws relating to building construction, and BOILER-COAT(3 H.P.Or 100,000 B.T.U.) 6.00 AC
hereby authorize representatives of this city to enter upon the 801 LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep ham9ess 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 conuquence of the PERMIT ISSUANCE 10.00
grant got this P< 1. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Ignature of Applican ontractor ale
OFFICE COPY