13507 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDWP,,R9JECT IDENTI FICATIONPERMIT NUMBER• s,
BUILDING r -'') APPLICATION & PERMIT
ADDRESS /` �.l BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 13507
TIV
OWNER'S PLAN CHECK VALIDATION
NAMEQTY. ELECTRIC PERMIT FEE
HONE
CONT ACF , _T! - L UTLETS-SWITCHES-RECEP 10.00/1.00
-,UC.No. y LIGHTING FIXTURES 10.00/1.00
CONTRACTOR s�C y�--� - PPLIANCES-RESIDENTIAL 4.00
AooREll
I s r` PHONE CQ 6e--714 tI PANELS 10.00 DATE OF APPLICATION'
ARcwTwTPANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE .GN .
OR
ENGINEER 1
LIC.ND. ISIGNS TRANS. 3.00
ARCHE OR
ENG' SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP rEMP.METER OR POLE INS. 20.00
APPLICANT'5 MOTORS SEE FEE SCH.
AOORE56
CA SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION C /
<v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
<n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, I PLG. MECH.
H N i Professions Codt and-mv license is in full force apd 5ffrfy6
z O m - Liccnu,.Clpss :3 g Lic.Number '!4
" u, f a D contract,,
T ON�n nSi BUILDING PERMIT
m w 3 OWNER-BUILDER DECLARA I - INFORMATION
w °
e H I hereby affirm that I am exempt from the Contractor's LicenseMISC.- REFER TO ORD
LL04 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION 5/FT.
� - 0 Code:Any city or county which requires a permit to construct,alter,
Q u,¢ 2O Improve,demolish.or repair any structure,prior to Its Issuance,also ELEC.CONTR. LIC
ELEC.
- °LL requires the applicant for such permit to file a signed statement that a TOTAL PERMIT TO
K
$ he is licensed pursuant to the provisions of the Contractor's License /
Hzi
Law(Chapter 9(commencing with Section 7000)of Division 3 of the is �J L8
x o Business and Professions Code)or that he is exempt therefrom and QTY- PLUMBINGaPI MITO FEE
I[ r the basis for the alleged exemption.Any violation of Section 7031.5 %\n, (\ STORIES TYPE CONSTR.
d ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&NVENT- AT RE EA.) 5.00
of not more than I've hundred dollars(S500).): U
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROT GT,.D VICE 4.00 OCC.GROUP REB.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec 7044, Nusinas and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code:The Contramor's License Law does not apply to an owner of _
properly who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 ' so.Fr.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- ^,
ments are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-l1NC.40UTLETS 6.00
or hnpmvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
provefor purpose ofsale.). INDUSTRIAL WASTE INTER. 30,00 RES IND CON PB omen
❑ I,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 A55 RS 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(EA.) 1.00
contracts for such projects with a contracturls)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I ani exempt under See. ,BAP.C.for this WATER HEATER W/V T 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC,FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREATINGE. Jt� 5.00
I hereby affirm that I have a certificate of consent to self-insure, \ Y ZONING
or a certificate of Workers'Compensation Insurance,or u certified 7 ENG.SITE NO.
cog,�thereof(Sec.3500,Lab.C.). (s\pe
Polley No. Company F (LV✓agr•S ys�
0 Ch Certil ed ropy is hereby furnished. \" FIRE SPRINK ENERGY T 24
Z Z ❑- Certified copy is filed wi Hi the city inspection division.
O Applicant SCREFER- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
CC 'CER'TIFICATF OF EXEMPT]ON I7ROM WORKERS' PERMIT ISSUANCE 10.00 C) _^ FLOOD ZONE A.L.U.D.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. ~
0_Z 1' 1'his section need not be completed D
if the permit N for one TOTAL Q Y❑ NE] Y ❑ N❑
hundred dollars(S 100)or less.)
U O I certify that in the performance of the work for which this per. QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
Q.Ed Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING -
} res NOTICE TO APPLICANT: If,alter making this Certificate of Ex-
F.. ? emptfon,you should became subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 1O=C.F.M.) 4.00
CONSTRUCTION LENDINGAGENCV AIR HANDLING UNIT(OVER 10,000 C.F.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(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nam
Lender's NAdd o. HEAT]NG UN IT(OV E R 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COM (3 H.P.or 100,000 B.T.U.) 6.00 TL
authorien representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned progeny for inspection purposes.
0110 agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, casts and expenses which CONST.TAX
Cray in any wa ace 'nst said City in consequence of the PERMIT ISSUANCE 10.00
grant m ran' MECH.CONT. LIC.NO. MECH.
/.240 TOTAL TOTAL
'gnat o Applicent/co Date
OFFICE COPY