13406 _ -APPLICANT TO FILL-IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJEC IDENTIFICATION ,PERMIT NUMBER
APPLICATION & PERMIT 13406
A
BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
AARCHITECI&a,,�&
PLAN CHECK VALIDATION
/i TY. ELECTRIC PERMIT FEE
PHo GCONTUTLETS-SWITCHES-RECEP 10.00/1.00
LIc.Ro LIGHTING FIXTURES 10.00/1.00
PPLIANCES-RESIDENTIAL 4.00
PHPANELS 10.00 DATE OF APPLICATION
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
- tic.No. SIGNS TRANS. 3.00
AAACHOR DDRESS ENL. SPECIAL CIRCUIT 5.00 PERMITVAEIfJATION
—TEMP. METER OR POLE INS. 20.00
"P A" MOTORS SEE FEE SCH.
A OAI7,r-
SERVICE CHANGE 20.00
w o o LIC17NSED CONI'RACTOR DECLARATION ( n
u t I hereby affirm that 1 am licensed under provisions of Ch.ptcr 9 ISSUANCE DATE
a i W
(commenting with Section 7000)of Division 3 of the tlusiness an BLDG. ELECT. PLG. MECH.
rD i Professions Cody•�tsyp •nse is in full force a
f. z o"vj - Licenu Cla l.- Lic.NumberEl El El
0 z H 0 Dmc ut. or _ -
" is 3 o BUILDING PERMIT
cert re ¢ OWNER BUI UER UECLA RAT N
A o Asa MISC.- REFER TO ORD INFORMATION
v I hereby affum that 1 ain exempt from the Contractor's License VALUATION s/FT.
Fwoa
Law the following reason.(Sec.]03 L5,tlusincssanJ Profusions PERMIT ISSUANCE 10-00
Code:Any city or county which requires a permit to construct,alter,
re u, ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- 0 u requires the applicant for such pemsit to file a signed statement that TOTAL P gAtrr TO
A w m he is licensed pursuant to the provisions of the Contractor's License -
F.ii
Law(Charter 9(commencing with Section 70000ol'Division 3 of the /l/fL vl
- ¢ Business and Professions Code)or that he is enempt therefrom and OTY. PLUMBING PERMIT FEE
ce - the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
w. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5,00 or
of not me than five hundred dollars($500).:
❑ 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 she work,and the structure is not
intended or offered for sal. (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 6.00 yd Fr,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
menu are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I1NC.4OUTLETS 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 for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Dmn
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to comtmct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
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 IEA.) 1.00
contracts for such projects with a contractions)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for suis WATER HEATER W/VENT 6.00
reason
13 Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
(� PEs ON DIicLARAT1oN WATER TREATING EQUIP. 5.00
hereby affirm that I have a certificate of coment tuself-insure, ZONING ENG.SITE NO.
r a crefR of Workers'Compen nsur n fi
copy thehereoof(Sec.38(10,Lab.Cd. !
Policy No. Company
❑ Certified mpyl byfMhAi
FIRE SPRINK ENERGY T-24
Z 2 ❑ Ce.f d co Is Ileo spection division. MISC.- REFER TO ORD.APPlicanl - Y ❑ N❑ Y ❑ No
CC RTIFICA i OF XEMPTION FROM WORKERS'rn PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
� CEE
L COMPENSATION INSURANCE - PLG.CONTR. LIC.NO. PLO, Y❑ N❑ Y ❑ IN
_ (This section need not he completed if the permit Is for one TOTAL
hundred dollars(SI W)or less.)
U O 1 certify that in the performance of the work for which this Per- CITY. 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 Califomia.
UJ Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of F-a-
F 2 emptum,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of she tabor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVEA 10=CF.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) MSCH. M
the performance of the work for which this Permit u issued ISec. HEATING UNIT(TO 100,000 B.T.U.) FILM
3097,Civ.C.).
Lenders Name HEATING UNIT(OV ER 100,000 B.T.0
Lender's Address RIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE)
information is correct. 1 agreetocomply with all city and county ING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.
hereby authorize representatives of this city to enter upon the BOILER-COMP tOVo 100,000 BTU)SEE F NICALabove-mentioned property for inspection purpose(We) agree to save, i nify and keep hamiless the City of MISC.- REFER TOCupertino again b' Ie jus, said 4 creta enexpenses which .TAXma rue gains( vin City in cone uenceqqq[[[the PERMIT ISSUANCE
g lln8 t ME .CONT. LIC.NO. TECH.
' ' SSSYYY
To Ign are o Ap icant/Cont a[or Uete � Tao / TOTAL
F I E PY