13276 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION U PERMIT ����
/,DORE59(�O
In CA
399-1 ..I �I BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
UWNER'S I `l PLAN CHECK VALIDATION
S "AME C p s QYY. ELECTRIC PERMIT FEE
C ox 35g,-3w
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CONTRACTOR S NA6� UTLETS-SWITCHES-RECEP 10.00/1.00
NFME
QJ` 1 sac.No ��`'� (0 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS +am,�f,_n!1 PPLIANCES-RESIDENTIAL 4.00
FDORES9 f"�-e'r-
p,-4iLli Ln PH 37 - PANELS 10.00 DATE OF APPLICATION
on
CHITE T PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESOR S ENG' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 /1
APPLICANTS MOTORS SEE FEE SCH- ( -s �
ADDRESS �O WC�J
SERVICE CHANGE 20.00
�T
w o Z.
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LICENSED CONTRACTORS DECLARA'f1ON I
a it U I hemby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
n Q w (commencing with Section 7000)of Division 3 of the Business end BLDG. ELECT. PLG. MECH.
H N i ]"Ofic ncuS Codly and my license n in full lure and effect. ❑ ❑ ❑
Z o m - Lice C ass Lm Nmhtw
O z F w Da lc Contract,
¢ r s - - BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DP LARATION
¢ w u INFORMATION
w0 n I- 1 hereby (firm [hat 1 am exempt from the Contractor's License MISC.- REFER TO ORD -
LL a p 17D
S/FT.
H _ v, law for nycihe t llowingreywhihrequi3sit Permit
to consand truct,
-PERMIT ISSUANCE 10.00 Code:Any city orcounty whichrequiresa Permit to construct,alto,
¢ ¢ 0improve,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
' w he is licensed pursuant to the provisions of the Contractor's License
aa z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
- ¢ Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢ _ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicantfor a Permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 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 no[
intended or Offered for sak (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
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 Sa 1.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
Res IND Cory PB ,suer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
Cl 1.as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPARCELNO.
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 for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SAN)TAR Y-STORM EA.200ft/l 0.001 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.AP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC,DATE ACL.FILE NO.
WORK F-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 -
1 hereby affirm that I have a certificate of-consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a Certified ENG.SITE NO.
copy N fIScc.38 , pang ). R $
Policy ie ompany 5
O Certitue copy ishemby fumiahe FIRE SPRINK ENERGY T-24
Z z �Cerld COPY IS filed,�Wtl 0 city inspersion division.
O Applirmt swx.«-A � (j.. - MISC.- REFER TO ORD. Y❑' N❑ Y ❑ N❑
~ va � PERMIT ISSUANCE 10.00
TIPICATE_( EXEMPTION FROM WORKIi RS' FLOODZONE A.L.UC.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG. y[:] N❑ Y [:] N❑
Z (This vection need not be completed if the permit u for one TOTAL
hundred dollars IS 100)or less,)
U O 1 certify that in the performance of the work for which this per- FEE SUMMARY
LL F mit u issued,1 shall not employ any person in any manner So as to QTY' MECHANICAL PERMIT FEE
O become Subject to the Workers'CompensTtion Laws of California.
O G.Lu Dam Applicant ALTER OR ADD TO MECH. 5,00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become Subject to the Workers'Compensation APPLIANCEAW
5.00 PLAN CHECK
provisions of the tabor Code, you most forthwith comply with r
FEE
U such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10M0.F..9) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC1F.M.) 6.00 SEISMIC FEE
1 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 tSec. 1 )t� OO MICROFILM
3097,Civ.0.). I HEATING UNIT (TO (00,000O3.TU.I B.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.19.50
Lender's Address ELECTRIC
• I certify that I have read this application and state that the above a- VENTILATION FAN (SINGLE) 4.00 vO
information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and B0ILER-ODKV(3H.P.or10O,000B.T.U.) 6.00
hereby authorize mpmacniatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL /
above-mentioned property for inspection purposes.
(we) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Bal iBties,judgments, costs and expenses which PERMIT ISSUANCE 10.00 I CONST.TAX
may any way accrue against said City in consequence of the 0.
grangN ng of this permit MECH.CONT, LIC.NO. MECH.
-7171Y-7 TOTAL TOTAL
gnilum odfApplicant/Contraotbr Date 3�•�/
OFFICE COPY