13844 f
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDIADDRENG APPLICATION & PERMIT 13844
./J..✓ t BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
�X� vDo
OWNER'S PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
�`1 PHONE
CONTRACTORS � /� LIC.NOUTLETS-SWITCHES
-RECEP 10.00/1.00
NAM
.}fit LIGHTING FIXTURES 10.00/1.00
t 1 . L
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESSq 1'
�� - /LJry PANELS 10.08 DATE OF APPLICATION
ONE
ARCHITECT
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO, SIGNS TRANS. 3.00
ARCH.OR ENL. 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT q�
ZIP EMP.METER OR POLE INS. 20.00 4�µd11UT
eooeessTS MOTORS SEE FEE SCH. I„
�O_ l( SERVICE CHANGE 20.00 e��f�' y
0 0 2 LICENSED CONTRACTORS DECLARATION M,
a.IH I hereby affirm that I am licensed under provisions of Chapter 9 SSUAN DMTEH..
H at w (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG.'] MECH.
H o i Professiom C ,a y license is in fill[fore d T c ❑ ❑ ❑ ❑
z 0 n- License C ass. _ Lic.Number
o z H Dale Contra - -
Q Y g BUILDING PERMIT
OWNER-BUILDER DECLARATION INFORMATION
wI hereby offirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
.. Cis for the following reason.(Sec,7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION SIFT.
L Code:Any city or county which mquireae Permit toconstruct,alter,
SQ p improve,demolish,or repair any slruclum,prior to its issuance,BM ELEC.CONTR. LIC.NO. ELEC.
D LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w he is licensed Pursuant 10 the provisions of the Contractors License
Hzi
Law(Chapter 9(commeneing with Section 7000)of Division 3 of the
a Business and Professiom Code)or that he is exempt Ih...hen,and QTY. PLUMBING PERMIT FEE
the besis for the alleged exemption.Any violation of Section 7031.5 TORIES TYPE CO r.
by any applicant for permit subjects the applicant loacivil Penalty ALTER-DRAIN&VENT-WATER (EA-) 5.00
of not more than five hundred doll..($500).1: i I
❑ I,as owner of the property,or my employees with wagesas BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cade:The Contractor's License law does not apply to an owner of
property who builds m improves thereon,and who docs Such work F IXTUR ES-PER TRAP 5.00 :ser IT.FLDOR AREA TOTAL ACREAGE
• himself or through his own employees.Provided that such ini Prove- i.
Rents are not intended or offered for Sale.If,however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
orimprovement is sold within one year of complelion,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- RES IND CON PB Omar
prove for purpose of sale). INDUSTRIAL WASTE INTER. 30.00
❑.1,es..net of the property,am exclusively contracting with ❑ El ❑ El
licensed contractors to mustme, 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 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 Io
the Contractor'spt under
Law. SEWER-SAN EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Iamexempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.002iH ACC.DATE ACL.FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofcoreent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compans do i Insurance,or a certified
copy thereof(Sec.3800,Lab.C.). _
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
z Z ertified y is with the city inspection division. MISC.- REFER TO ORD.
A piicaps Y El NEI V ❑ IN E]
O
'y PERMIT ISSUANCE 10.00 vL000 ZONE a.L.u.c.
Cr CERTIFICATE OF EXEMPTION FROM WORKERS'
W > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. Y❑ N❑ Y❑ N❑
CL (This section need not he completed if the permit is for one TOTAL
:) 2 hundred do11un($1001 or less.)
U O 1 certify that in the performance of the work for which this Per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL H 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.
Go Datc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become 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 dccmed revoked AIR HANDLING UNIT(TO 10SMCF.M.) 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 6.00 SEISMIC FEE
I hereby uffmm that there is a construction lending ugvocy for EXHAUST HOOD(WITH DUCT) 5.00
the perlormance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT IO VER 100,000 B.T.U.)9.50 ELECTRIC
Lender i Address
I certify Iha I have read this vpplicalion and slate that the above VENTILATION FAN (SINGLE) 4.00
ordinances and state laws relating
n Correct.I agree to comply with all city and county PLUMBING
ing to building construction, and BOILER-eoNtP I3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(O.er 100,010 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(WO agree to save, indemnify and keep h DRICYS the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may N any P cot Said City in consequence of the PERMIT ISSUANCE 10.00
granli is is pe rL MECH.CONT. LIC.NO. MECH.
6� q�14I �7 TOTAL TOTAL I 60
Signal. of Applicant[/Coniraelor ale
OFFICE COPY