13241 L(. F. TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
FU•,✓DrIJuPG APPLICATION & PERMIT t
C BUILDING —ELECTRICAL—PLUMBING—MECHANICAL 13241
-g 9 9kli
PLAN CHECK VALIDATION
.
NAME
QTY. ELECTRIC PERMIT FEE
PHONE
CONTNAMERACTOR's UTLETS-SWITCHES-RECEP 10.00/1.00
1 L LIC.No. 7 LIGHTING FIXTURES 10.00/1.00
CON e � /ACTCR �r PPLIANCES-RESIDENTIAL 4.00
0,0 PRONE 3_)1—y6_2 PANELS 10.00 DATE OF APPLICATION
A CRIT Ci
on PANELS (OVER 200 AMP) 2(7.00 PLAN CHECK FEE P.C.NO.
ENGINEER
' Lac RE. SIGNS TRANS. 3.00
ADDRRESS ENc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
nv TEMP. METER OR POLE INS. 20,00
APPLI EMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20,00
o �
02 �/Q
Foo LICENSED CONT RACTORS DECLARATION (/�f
G U w I hereby afOrm that I am licensed coder provisions of Chapter 9 ISSUANCE DATE
Z (commencing with Section 7000)of Division 3 of the Business anJ
3 i Professions Code,a m license is in full force and lf (�,..� BLDG. ELECT. PLG. MECH.
z o B License Class Lic.Numner u6--1 L.
2 m Date Contr�ctor��R(�
Q y J
¢ LL OWNER-BUILUIiR DIiCLARA'fION BUILDING PERMIT
X
e N 1 hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO ORD INFORMATION
R,LLO4 Law far the followingrcason.(Sec.7031.5.tlusinessend Professions pEflMIT ISSUANCE 1000 VALUATION SIFT.
my Cale:Any city or county which requires a permit locons,mcl,alleq
x ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ,LEC.
— DLL requires the applicant for such permit to file a signed statement that TOTAL
a whe is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Rzi 4aw(Chapter 9(commencing with Section 70000.1'Division3 ofthe
¢ o Business and Professions Cafe)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ I—othe basis for the allege exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
e. by any applicant for a permit subjects the appplicanl ma civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(SSOR):
❑ I,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 stmctum is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law dues not apply to an owner of
S property who builds or improves themon,and who doef such workFIXTURE$-PER TRAP 5.00 = So,FT.FLOOR AREA TOTAL ACREAGE
'himself or through his own employees,provided that such improve-
menuarcOut intended oroffered for sale If.however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00 '
Liimprovement is sold within one year of complel ion,the owner-
builder will have the burden of proving that he did not build or no- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of sale.). RES IND CON PB Ocher
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00
licensed contractors to enco uct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 6 V.B. 600 ASSESSORS PARCEL NO.
and Professions Code:"1'h,Convectors License Law docs 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(%)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ [amcxcmptunder See. ,B.&P.C.f.rihis WATER HEATER W/VENT 6.00
reason
Owner 'Date 1 WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EOUIPu1 5.00
I hereby affirm that I have a cerliticum ofcoment In self-insure �{7♦
or a certificate of Workers'Compensation Insurance,or a rettified - ZONING ENG.SITE NO.
copymere f(�S�y.r1(%lan.c.).
Policy ere any
❑ Certified copy Is hereby furnished. 1
Z Z IJ Certifmd copy is coed with the city inspection division.
FIRE SPRINK ENERGYT]a
FO Applicant MISC.- `a R FE.1TObRD. YE] NE] Y ❑ NE]
y' CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE OX v 10.00 0 PL000 ZONE A.L.I.C.
LU > COMPENSATION INSURANCF PLG.CONT'H.CL 0 LIC.NO. PLG.
(This section treed not be completed if the permit IS for one TOTAL 4 Y❑ N O Y E] NEI
:DZ hundred dollars IS 100)orleM.)
U O -1 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
Ed Uasc APPIiCam ALTER OR ADD TO MECH. 5.00 BUILDING
} LC NOTICE TO APPLICANT: If,after making this Certificate of Iii-
F _ emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisiotu of the labor Code, you must forthwith comply with FEE .
U sock provisions or this permit shall be deemed revoked. ALJ
IR HANDNG UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)8.50 ELECTRIC
• 1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 .(,s
information is correct. I agree to comply with all city and county PLUMBING // ['V
ordinances and state laws relating to building construction, and B01LER-COMP(3H.P.or100,ODOB.T.U.) 6.00 ((
hereby authorize roprrtyfor ins of this city to toter upon the BOILER-COMP IDVBr 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property forinsp ofth i purposes.
(We) agree to save indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichCONST.TAX
may in any way accrue,against mid City in consequence of the PERMIT ISSUANCE 10.00
granlinpofthis pcm MECH.CONT. LIG NO. MECH.
nP�p T,� l 7�/ •, TOTAL TOTAL
S�ignatum of Appbcant/Contractor U tc
OFFICE COPY