13409 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PFJ QCT 1 DENTI FIC I N - PERMIT NUMBER
' BUILDING APPLICATION & PERMIT
R D BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 13409
1. BW R'S PLAN CHECK VALIDATION
• " QTY ELECTRIC PERMIT FEE
PHO
Co
AcmR's OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.N LIGHTING FIXTURES 10.00/1.00
roN Rs / PPLIANCES-RESIDENTIAL 4.00
AD
PHO PANELS 10.00 DATE OF APPLICATION
ARcwTECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.rvo. ISIGNS TRANS, 3.00 .,nj�•
ADDREOR SS ENG SPECIAL CIRCUIT 5.0.0 //PERMIT VALIDATION
ZIP. EMP.METER OR POLE INS. 20.00 4t 31 19,
ICA 's MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 Cry f 0111;dl
n
O o LICENSED CONTRACT RS DECLARATION (/� L
a,u v I hereby affirm that I n 000)of under provisions of Chapter 9 ISSUANCE DATE
H Q H (commencing with Section 70001 of Division 3 O(tlle Business' d BLDG. ELECT. PLG. MECH.
H N z Professions Cod cense is in full fo��IN
'❑ ❑ L� ❑
z o m- Lice a Inns Lis.Numbero USIC ContractoraYfBUILDING PERMIT
OWNER-BUILDERDECLAINFORMATION
A.
3 LL uHi I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL 0 4 Law for the following reason.(Sec.7031.5,Busincssand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
5 1, 1 Code:Any city or county which requiresa permit to construct,alter.
ac improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O R requires the applicant for such permit to rile a signed statement that TOTAL RMIT O
e. w m LL he is licensed pursuant to the provisions of the Contractor's License
Hz > Law(Chipter 9(commencing with Section 7000)of Division 3ofl he t -
4 Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE Z.....- S
H$ the basis for the alleged exemption.Any violation of Section 7031.5
STORIES - PE CONSTR.
by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500LL
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not DEC.GROUP RES.UNITS
intended or offered for sale (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 does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such atimprove- GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
improve-
mems are not intended or offered for sale.If,however,the building
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 Ile did not build or int-
' RES IND CON PB Omar
prove for purpose of sale). INDUSTRIAL WASTE INTER. 30.00
❑ L as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ Cl
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professloms 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 Willi a contractoos)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sce. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
cr Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
OR'L ' OhPENSATION UECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsemt loself-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compcpsa�Iq�Insun c
ropy thercol'(Sec.3800,Lnb.C. r,t
Policy No. 'Company-INV_Y�1
0 ❑ Certified copy is hereby furnished. RE SPRINK ENERGY T-14
Z Z ❑ Certified copy is filed with the city inspection di sion. MISC.- REFER TO ORD. N
0 Applicant Y❑ N❑ Y ❑ N[:]
I- W PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C.
LU CIiRTIFICATEOI°I?XEMPT INS FROM WORKERS'
DJ _ - need of be comIONpleted
INSURANCE PLG CONTR. LIC.NO. PLG. Y❑ N❑ Y❑ N❑
D' � (This Sec1i00 need not be complcl,d if the permit is for one TOTAL
D Z hu mired doll.rs(S 100)or less
U 0 1 certify that in the porformmlee of the work lir which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued, I shall not employ any person in any mannerso as to
U become subject to the Workers Compensation Laws of California.
y Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: IL after making this Certificate of Ex-
� Z Cntption,you should become subject In the Workers'Compensation APPLIANCE 5.00 PLAN'CHECK
provisions of the Labor Code, you must forthwith comply withFEE
C.1 such provisions or this permit shall he deemed revoked. AIR HANDLING NIT+(SO,10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0)000C,FM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST DOD,WITH.DUCT) 5.00
the performance 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 UNITC1
( VER -0,_ OB.T.U.)9.50 ELECTRIC
Lender's Address-
I
1 certify that I have read this application and slate that the above VENTILATION FAN ISINGLE) 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 FEESCH. MECHANICAL
above-mentioned prop, for inspection purposes.
(We) uJ r c, it emnify and keep hornless the Cil,of MISC.- REFER TO ORD.
Cupertino m .bili es,judgments, costs and expenses which NST.TAX
ma m a a ac a against said City in consequence of the PERMIT ISS ANCE 10.00
C
ng is t ME .CONT. LIC.N0. MECH.
-7--,2e f OTAL TOTAL
ignat reo A pliant/Contractor Date
i
OFF.'C8 COPY