13874 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT-1 DENTI FICATION PERMIT NUMBER
7 BBUUILDING Loj APPLICATION & PERMIT 13874
�t F5 Q BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OY.a.EA'a� PLAN CHECK VALIDATION
0. "AME, _ 9-7.1
ELECTRIC PERMIT FEE
W%WaM PRONE35�
CONTRACTORS UTLETS-SWITCHES-RECEP 10.0011.0077
ZPME
tJ"alrC'CIN L,G No LIGHTING FIXTURES 10.00/1.00
!i CONTRACTORsM a^ 11 PPLIANCES-RESIDENTIAL 4.00 -
ADDRESS Ice a�1�F
PANELS 10.00 DATE OF APPLICATION
ARCHITECTlZ PANELS (OVER 200 AMP) 20.00 . PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. .► SIGNS TRANS. 3.00
ABC EORR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rTEMP.METER OR POLE INS. 20.00
APPLICANTS
ADDRESS MOTORS SEE FEE.SCH.
SERVICE CHANGE �'u x'20.00 ,V
0 0 0 LICENSED CONTRACTORS DECLARATION p lr
a u I hereby affirm Ibat 1 am licensed under provisions of Chapter 9 C r ISSUANCE DATE
z w (commencing with Section 7000)of Division 3 of the Business and
� ,,y n - SLOG. ELECT: PILO. MECH.
H y Professions CgI and,Qly license is in full for�(a d f e
Z o 0 0 Lians�Cl'sy(�_J y Lic.NumbeCJ{[ �, ;1v �' ❑ ❑ ❑
Q m w Date- _ -1 ' g-1-_Contractor eR1
a y s 1N BUILDING PERMIT
a w OWNER-BUILDER DECLARATIO INFORMATION
woa MISC.- REFER TO ORD
LL I- I hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
HLL04 Law forthe following mason.(Sec.7031.5,Businasand Professions PERMIT ISSUANCE 10.00 Qi
Code Any city or county which requires a permit to construct,alter,
rt ¢ ¢ p improve,demolish,or repair any Structure,prior to its nuance,also ELEC.CONTR. LIC.NO. ELEC.
0 u requires the applicant for well permit to rile a signed statement that TOTAL PERMIT TO
X
$ he is licensed pursuant to the provisions of the Contractor's License
F z i Law(Chap ter 9(commencfng w i it,Seel ion 7000)of Division 3 of the
4 Business and Promaxiom,Ca l or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
QC the basis for the alleged exemption.Any violation of5ection 7031.5 STORI TYPE CONSTR.
di by any applicant far a permit subjects the applicant toa civil penally ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the properly,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 Oct.G oup RES.UNITS
their sole compensation,will do the work,and the structure is mot
intended or offered for sak (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law doers not apply to an owner of
property who builds or improves Ihemon,and who does 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.
menu are not intended or offered for sale.IL however,the Wilding GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or Improvement is sold within one year of completion,the owner- GASEA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- - RES IND CON PB OLso
prove for purpose of sale.). 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 ASSESSORSPARCELNO.
and Professions Code:The Contracrnr'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
contract,for such project's with a contr eons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I at,,exempt under Sec. ,B.&P.C.her this WATER HEATER WNENT 6.00
rcawn
Owner Date WATER SYSTEM 5.00
ACG DATE ACG FILE NO.
wORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have.certificate of consent 10 sel Ginsurt. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
1 the" 800.Lab.C.) 1
7- .is hembsluedyQ isherebyfurnished �V 1" FIRE SPRINK ENERGY T-Z4
fcJ w t Iy mspeclonI}tv�ion.
ZZO LN MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑h1t70 99 9 ON PERMIT ISSUANCE 10.00FLOOD zoNE A.L.U.C.
.- OP li%.. PTIDN FROF1 WORKIiRS'LU - MPENSATION INSURANCE PLG CONTR. LIC.NO. PLG. Y El
❑ Y❑ N❑
CL Z (Thu section need not be completed if the permit n for one TOTAL
hundred dollars(S 100)or Icss)
L) O .1 certify that in the performance of the work for which this Per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any perwn in any manner ren as to
become subject to the Workers'Compensa Hon laws of California.
d Dale ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex.
F.. ? eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall bM
e deemed revoked. AIR HANDLING UNIT(TO 10=CF. .) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT OVER IO,OODCEM) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perfannana of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l hmvread this application and stale that theabove VENTILATION FAN (SINGLE) 4.00
information Is correct. 1 agree to comply with all city and county PLUMBING
BOILER-COfoP(3 H.P.or 100,000 B.T.U.1 6.00
ordinances and stale laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP Over 100,OOB BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any.way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
ltg of this pgmit 1 MECH.CONT. LIG NO. MECH.
Ct 7 TOTAL TOTAL
ig tumor Applicant/ ctor Dat,-
OFFICE COPY