11514 APPLICANT TO FILL IN INFOR TION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROED C7 IDENTI FICA O - PERMIT NUMBER
APPLICATION & PERMIT
AD
J BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 11514
OWNEe PLAN CHECK VALIDATION
N°ME, OTY- ELECTRIC PERMIT FEE
PHONE
DANT A TORS
NAM UTLETS-SWITCHES-RECEP 10.00/1.00
nc.NolaLIGHTING FIXTURES 10.00/1.00
D
T
APPLIANCES-RESIDENTIAL 4.00
PHON IV PANELS 10.00 DATE OF APPLICATION
ARCHITECT
OR PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE .C.NO.
ENGINEER
LIc.No, SIGNS TRANS. 3.00
ARCH,OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00 PAZ
zIv � EMP.METER OR POLE INS. 2(7.00
cnrvrs MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 C_L�
w O o LICENSED CONTRA ORS DECLARATION' ty of Cupertino
< u U I hereby affirm that I am licenxd under provisions of Chapla 9 ISSUANCE DATE
w (commencing with Section 7000)of Division 3 of the Business d BLDG. ELECT. PLG. MECH.
zProfessions C S y license u in full fur
x o - Li loss Lic.Number ❑ ❑ ❑
9 w w. Date _ Contractor '
¢ y s BUILDING PERMIT
¢ ¢
-04WPJB-B UI LD ER D1:CLAR N INFORMATION
y I hereby affirm that I am exempt from the Contractor's Licenx MISC.- REFER TO ORD
LLo ¢ Law for the following reason.(Sec.7031.5,Businessland Professions PERMIT ISSUANCE 1000 VALUATIOry 5/FT.
� - Code:Any city or county which requires a permit to construct.alter,
rtQ¢Q improve,demolish,or repay any structure,prior to its issan
uce,also ELEC.CONTR. UC.NO. - ELEC.
- ¢ requires the applicant for such permit to file a signed statement that TOTAL - PERMIT TO
wm he is licenxd pursuant to the provisions of the Contractor's License
za Law.(Chaplcr9(commencing with Section 7000)of Division 3 ofthea
Busineand Professions Code)or that he is exempt therefrom and r.GAS
PLUMBING PERMIT FEE
M = the basis for the alleged exemption.Any violation of Section 7031.5 STORI TYPE CONSTR.
i ; � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not mote than Ove hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages asBACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
sole compensation,will do the work,and the structure h not
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code: The Contractor's License Law don not apply to an owner of
property who builds or improves Ihcrcon,and who does such workFIXTURES-PER TRAP - 6.00 SO.Fr.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
- menta are not Intended or offered for sale.If,however,the building -EA.SYSTEM-I IN C.4 OUTLETS 6.00
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 im-
prove of sated. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
1.as o
❑ L as owner
of the property,he project
(Se .7044,contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors od to The
the project(Sec.does,Business LAWN SPRINKLERS-1 INC 5 V.B. 8.00 ASSESSORS PARCEL NO.
and Professions Cade:The Contractor's License Law docs not apply
to owner of properly who ballon or improves Thereon.and who LAWN SPRINKLERS-OVER 6 IEA.) 1.00
contracts for such e with a contrmuctor(s)licensed pursuant to
the Contractor's LicLicenseL Lew. SEWER-SANITARY-STORM EA.200h/10.00 TRACT NO. -PARCEL No.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
re n
C/�Js/�..C�/�/. Date - WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
VIORL(Cf ' O P W SATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a ccrtiflcate ofcomens to self-insure. ZONING ENG.SITE NO.
or a cert ficata of Workers'Com Mir Ins car a cerlif J
copy thucof(Sec.3800,Iab.C.)r
Policy No. Company
0 ❑ Certified cop eby to ed. FIRE SPRINK ENERGY T-24
Z 2 ❑ Certified y u le she pection divi on.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
rn CERTIIrICAT OE E 'h1PTION FROM WORKERS' PERMIT ISSUANCE 10.00
FLOOD ZONE A.L.U.C.
LL > C PENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This xclion need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z:) Z hundred dollars(S 100)or It.)
U O I certify that in the performance of 0m 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 soas m
U become subject to the Workers Compensation laws of California.
U., Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} In NOTICE TO APPLICANT: If,alter making this Certificate of Es.
♦- ? emption,you should become subject to the Workers'Compensation APPLIANCE _ 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this pemnit shall 4 deemed revoked. AIR HANDLING UNIT(TO 10=QF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 6.00 SMIC FEE
I hereby aCfimn that there is a construction lending agency 1'or EXHAUST+HOOD (W ITHD UCT) 5.00
the performance of the work for which this permit is iaucd(Sec. - ICROFI LM
3097,CN.C.). HEATING UNIT(TO Lb,000 B.T.U.) 8.00
Lenders Name HEATI NG UN ITI(OVER'100,000 B.T.U.)9.50 ELECTRIC
Lender iAddress - k
. Icertify that l have read this application and slate that she above VENTILATION FAN (SINGLE) 4.0
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby azdhoriLe representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTUI SEE FEE SCH. MECHANICAL [r
above-mentioned properly for inspection'purposes.
(We) agree to say irI)i ify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against i it es,j dgments, costs and expenses which ONST.TAX
may m any we c e a nst mid City in consequence of the PERMIT ISS NCE 10.00
grants" lhi i / / ME CONT. LIC.NO. MECH.
fie� OTAL TOTAL 3 oG
Si of pplicantl ontractor De c
OFFIC :COPY