13687 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BUILDING PROJECT IDENTIFICATION APPLICATION & PERMITADDRESSAoo-ss , q2w_w5 CT I-oT2 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
PLA
NAMOWNERS I
r� 1 [. /1 , 117Y. ELECTRIC PERMIT FEE
,SSMC PHONE e
COATRACTORS C/U ,2j UTLETS-SWITCHES-RECEP 10.00/1.00 ,3
NA E /1 2
Lt]CUIWC;N, LIC.No. 7153 LIGHTING FIXTURES 10.00/1.00
r, NTRADTORs PPLIANCES-RESIDENTIAL 4.00
ADORE
PHONE PANELS 10.00 Oma- DATE OF APPLICATION
ARCHITECT
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENOINEER sic.No. SIGNS TRANS. 3.00
-
ARCH.OR ENO. 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP ' EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS C SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 ! /
4 7
o¢i 0
Foo LICIiNSEU CONE RACTORS DECLARATION
¢ v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
Q 2 w
(commencing with Section 7000)of Division 3 of the Business and ( f' C• 1�- BLDG. ELECT. PLG. MECH.
yi Professions Cade y license is in fall forS./Bnn¢C1ji . 3 ..t ) ❑ ❑
z o w; .icense x Lia Number T�Cll�r J 0
m F w . etc ConlraCl Or .dlJ
L1/'Lly'T(/ IIIA, rt(v`u BUILDING PERMIT
¢ rt w 4 OWNER-BUILDER DECLARATION �,-„ INFORMATION
X
a.
on
H I hereby affirm that 1 em exempt from the Ctractor's License MISC.- REFER TO ORD VALUATION SIFT.
Fweo� Law for the followingreewn.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
¢ a ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
O u rcluires the applicant for such permit to file a signed statement that TOTAL/177 PERMIT TO
w $ he is licensed pursuant to the provisions of the Contractor's License � p��
H a, i Lew(Chapter 9(commencing with Section 7000)of Division3of the "�-/
st Business and Professions Code)or thot he is exempt therefrom end OTY. PLUMBING PERMIT FEE
at Z p STORIES TYPE CONSTR.
¢ I- $ the basis for the alleged exemption.Any violation of Section 7031.5
e by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not mole than Ove hundred dollars(S500)J:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC,GROUP RES.UNITS
their wle Compensation,will do the work,and the strocture Is not
intended or offered for sale (Sec. 70,14, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractors License Law docs not apply to an owner of
property who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 5.00 So.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1 tNC.4 OUTLETS 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.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or ice- RES IND CON PB Other
prove for purpose of vleJ. INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with
licensed Contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASO.
and Professions Code:The Contractor s ESE RSPARCEL N
lCense Luw 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
SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ l am exempt under SCC. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reysOn
Owner [)ate WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
�WORKERS'COMPENSA'1'ION DECLARATION WATER TREATING EQUIP. 5.00
ffirm
oo aY then airtfJOL t alb,Lah.C.I p/I t � Writhed ZONING ENG.SITE NO.
Policy No. Company U-�'%���
Q ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T 24
z ❑ Card ed copy i f e with a city inspection division. MISC.- REFER TO ORD. y q� y N�
O Applicant _
� � CERTI it A I P h EM PTI(1N FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 C.
111 CON ENSATION INSURANCE PLG.CONTfl. LIC.NO. PLG. Y N Y N
CL O (This cacti need not be completed if the permit u for one TOTAL
Z hundred dollars(SIOO)or less.)
U O 1 certity that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
-LL F mit is issued, I shall not employ any person in any manner w as to
Om become subject to the Workers'Compensation Laws of California. BUILDING
Dao Applicant ALTER OR ADD TO MECH. 5.00
} w NOTICE TO APPLICANT: If,after making this Certificat,of E.-
F ? notation,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
prision of the Ube, Calc, you Insist forthwith comply with FEE
U sucovh provision or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CF.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOQEML) 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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
309],Civ,C.). p
Lender's Name HEATI NG UN IT(OV ER 1 DO,000 BY
_.T.U.)9.50 ELECTRIC
Lenders Address
I Certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree m comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property far inspection purposes.
(We) agree to save, indemnify and keep hornless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any wa ccrue against said City in consequence of the
granting Oft mh. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signal C 1 pp cant/Contractor D' e
OFFICE COPY