13280 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICATION. . PERMIT NUMBER
BUILDING Q APPLICATION & PERMIT
noon�as - xn 13280
3O"g 9S Jpu Lht2 `pCGt•K.2_ UILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
ELECTRIC PERMIT FEE TY.
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, L
croR's
NAME OUTLETS-SWITCHES-RECEP 10,00/1,00
NAME
LIC.NO. LIGHTING FIXTURES 10.00/1.00 '
CONTRACTOR'S ' APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
on
ENGINEER. '
LIC.NO. SIGNSTRANS. 3,00
ARCH,OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP '• EMP.METER OR POLE INS. - 20.00
APPLICANT'S_ IMOTORS SEE FEE SCH. /I -
ADDRESS
SERVICE CHANGE 20.00
••
'02
Oo LICENSED CONTRACTORS DECLARATION
< v I hereby affirm that I am licensed under provisions of Chapter 9 ' ISSUANCE DATE
I- rt n (commencing with Section 7000)of Division 3 of the Business and -
HBLDG. ELECT. PLG. MECH.
]i Professions Code,and my license is in full force and effect.
0 ar O License Class Lit.Number-
0 ❑ ❑ ❑
H w Date 'Contractor
¢ ys - BUILDING PERMIT
OWNIi R-BUILDER DECLARATION 'BUILDING
wo ° MISC.- REFER TO ORD VALUATION s/Fr.
3:n y I hereby affiant that I am exempt from the Contractor's License
Ftw o j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Q,A Code:Any cityor county which requires a permit to construct,alter,
c < 0 improve,demolish,or repair any structure,prior to its issuance,also ELE C.CONTR. LIC.NO. ELEC. ✓(�'(�
O u
requires the applicant for such permit m file a signed statement that TOTAL E MIT
whe is licensed pursuant to the provisions of the Contractor's License //!//
H z i Law(Clsapwr 9(commencing with Section 7000)of Division 3 of the
4 c Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE 2
¢ s- the basis far the alleged exemption.Any violation of Section 703 LS STORIES TYPE CONSTR.
d; by any applicant for a permit subjects the applicant oo civil penalty ALTER-DRAIN III VENT-WATER (EA.) 5.00 '
of not more than five hundred dollars($500).): I
❑ I,us owner of the property,or my employees with wages us BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,wili'do the work,and lire structure is not
�1 intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
® property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 6.00
mems ore not intended or offered for sale.If,however,the budding
or,improvement is sold withid one year of completion,the owner- GAS•EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or an., BUILDING USE
RES
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 - INO PB Omar
-, ❑ I,as owner of the property,am exclusively contracting with ❑' El El
❑ 1-1 11
licensed contractors to construct the project(Sec.7044,Business LAWN SPR INKLERS-.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 (EA.) 1.00
contrathe Contract su License
with a comraclor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Lew..
❑ Iamexemplunder Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason - -
Owner Date WATER SYSTEM ' 5.00 ACC.DATE ACC.FILE NO.
u KERs'coMPENSA'fION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have'a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab,CA '
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
_Z 2 ❑ Certified copy is filed„with the city inspection division. MISC.• - REFER TO ORD.
Q Applicant - - Y ❑ N❑ Y ❑ N❑
Fy PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 C.
� CIiRTIFICCOWIPE EXEMPTION FROM WORKERS' -
W � COMPENSATION INSURANCE Plc.CONTR. LIC.No. PLG,
CL a Z ❑(This section need not be,completed if the permit is for one TOTAL Y NE] Y [:] N❑
hundred dollars($100)or las,)
U O 1 certify that in the performance of the work for whichthis per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
W I. 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.
W Date-Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING
). W 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 deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY 'AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE,
1 hereby afO,. 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.0.). t). - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's AddressHEATI NG UNIT(OV ER 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. 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 authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(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 any way accrue against said fly in consequence of the PERMIT ISSUANCE 10.00
ID ti flh' ermit. MECR CONT. LIC.NO. MECH. TOTAL Aft
OCH. /
S na are of Applicant/Contractor D;dr
OFFICE COPY
1