1341210. A;�PPLICANT.TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PRO IDENTIF ATIO
APPLICATION U PERMIT
UILDING -ELECTRICAL- PLUMBING -MECHANICALPLAN
PERMIT NUMBER
13412
CHECK VALIDATIONOTY.'
kBING
ELECTRIC PERMIT' FEE
s
'LIC. "C
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
cAs
A o
APPLIANCES -RESIDENTIAL 4.00
PANELS W.00
PRG
DATE OF APPLICATION
ARCHITECT
OR
ENGINEER
uc, NO
PANELS (OYER 200 AMP) 20.00 •.
PLAN CHECK FEE P.C. NO.
ISIGNS TRANS. 3.00
noo ass ENG.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
-
A CANTrs
flE
MOTORS SEE FEE SCH. '
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
r
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Sept 7000) Of Division 3 of the usi ass d
Professions Cals�Yd ILnlicense is in full fort
License Class C.� vV Lia Number
SEDANCE DATE
BLQGIELECT. PLG. MECH.
YI-1.
❑• 11� w' ❑
DatContractor
75
,
W � 4BUI4DING PERMIT
t I
IN�QR�iIfIT;ION
OWNER -BUILDER DECLA A ON
I hereby affirm that 1 am exempt from the Contractor's License
Law forthe following reason. (Sec. 7031.5, Business and ProfessionspERMIT
Code: Any city orcounty which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
MISC. - REFER TO ORD
ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTR, LIC. NO. %LEC.
.. ' - TOTAL
QTY. i F *" 'PLUMBING PERMIT
gTORIE
CONSTR.
by any applicant fora permit subjects iicanttoacivil penalty
of not more than five hundred dollars ($500).5000.):
ALTER-DRAIN-WATER(EA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00 -
OCC. GROUP
RES. UNITS
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
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 5.00
SOL FT. FLOOR AREA
.
TOTAL ACREAGE
GAS-EA.SVSTEM-I 8.00
or improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or im-.
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
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 - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec. ,BAP.C. for this
reason
WATER HEATER W/VENT 6.00
Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
' MPENSATION DECLARATION,
1 hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compens tion Insura ce ora er ilia
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800,
Policy No. Company
❑ Certified copy is h rebyf a .•
❑ Certifiec IS 11 Ih JJy- division.
Applicant
FIRESPRINK
v ❑ N ❑
ENERGY T-24
v ❑ N❑
MISC. - REFER TO ORD.
CHI A F.OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
(This section need not be completed if the permit -is for one
PLG. CONTR. „ _ LIC. NO.
TOTAL
Y ❑ N ❑
Y [:] N ❑
hundred dollars IS 100) or less.)
I certify that in the performance of the work for which this per
mit is issued, I shall not employ any person in any manner so as to,
become subject to the Workers' Compensation Laws of California.
Date Applicant
�UTV. F MECHANICAL PERMIyT, 'FEE'
q
FEE SUMMARY .
BUILDING
'
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after ranking this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
APPLIANCE 5.00
AIR HANDLING UNIT (7010A00C.F.M.) 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (OVER 10p00C.F.M.) 6.00
SEISMIC FEE
'
' CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
EXHAUST HAIIWITH DUCT), 5.00
the performance of the work for which this permit is issued (Sec.
3097, CN.C.). t
ICROFILM
HEING NIT (TO 100,000 B.T.U.) 8.00
AT U
Lender's Name -
Lender's Address
HEATING UNIT I VERA O�OOOj '- .U.19.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
I certify that I hive read this application and state.thal the above
information is correct. I agree to comply with all city and county--PLUMBINGBOILER-COMP(3
ordinances and state laws relating to building construction, and
H.P. Or 100,000 B.T.U.) 6.OQ
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives ofthis city to enter upon the
hipurposes.
above-mentioned property for inspection
(WE) agree to save 1 RBB and keep harmless the City of
Cupertino ago'B li ilitie judgments, costs and expenses which
m y any y ecru gainst said City in consequence of the
MISC. •, REFER TO ORD.
-CONST. TAX
pERMIT SSUANCE 10.00
rani is p
4 7-
M .CONT. LIC. N0. MECH.
q OTAVL?
J
TOTAL
33
nature of Applicant/Contractor - Dace
OFFICIO COPY