13881-APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
13881
BUILDING r
ADDRESS
WTA'
N
OWNER'S
NAME ^I., /�
G Gt01, PHONE ,J 5-2.I
OTV. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION '
NAMERAcr Rs ,
UTLETS-SWITCHES -RECEP 10.00/1,00
LIGHTING FIXTURES - 10.00/1.00
Lie NO.
CONTRACTRs 7_7-0-TW(t'�/
APPLIANCES -RESIDENTIAL 4.00
74,A .bi (/J PHONE
PANELS 10.00
DATE OF APPLICATION
ARCHITECT T -I ♦
GR "1
ENGINEER
uc, NO
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. N0.
SIGNS TRANS. 3.00
AARCH. OR DDRESS ENG, -
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00.,20 -
IF//
LICENSED CONTRACTORS DECLARATION
-7 IS 7
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of The Business and
Professions Code, and my license is in full force and effect
License C Lia Number
ISSUANCE DATE
BLDG.
❑
ELECT.
PLG. MECH.
F_❑
Date Contractor
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 um exempt from the Conactor's License
tr
Law fo the (Sec. requires a permit town Professions
Code: Any city or county which requirese permit toconstruct,,
MISC.- REFER TO ORD
PERMIT ISSUANCE ( 10.00 --
VALUATION
S/FT,
ELEC. CONTR. LIC. NO. ELQQ
TOTATAL V
DTV`. PLUMBING PERMIT FEE
also
improve, demolish, of repair any structure, prior 10 its issuance, also
requires the applicant for such permit to file a signed statement that
pursuant to the provisions of the Contractor's License
he is (Chapter 3 of the
Lawasiness d Professions
Business and Professions Code) or That be is exempt therefrom and
Codeng with Section 7s 00) exempt therefrom
PERMIT TO
t [£sem
tate of Section 1.5
the basany
dermitsubje
STORIES
TYPE CONSTR.
plica malty03
by any oomtha fora permit subjects(S500plicant toacivil penalty
fora subjAny ects
of not more than five hundred dollars (5500).1:
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
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner n1'
FIXTURES - PER TRAP 5.00
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsarenotintendedorofferedforsale. If, however, the building
SQ FT. FLOOR AREA
TOTALACREAGE
GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or Improvement is sold within one year of completion, the owner-
builder will have the burden of proving that h e did not build or im-
prove for purpose of sale.).RES
❑ 1, as owner of the property, am exclusively contracting with
.
GAS - EA. SYSTEM -OVER 4 IEA) 2.00
BUILDING USE
IND CON PB OIna
❑ 1:1 ❑ ❑
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 forsuch projects with a contractors) licensed ptvsuant to
the Contractors License Law.
SEWER -SAN V -STORM EA. 200ft110.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sac.-, B.&P.C. for this
WATER HEATER W/VENT 6.00
on
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKERS'COMPENSATION DECLARA710N
1 hereby :ithim that I huvo a certificate of conscut to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab.C.).
Policy No. Company
FIRE SPRINK
Y[] NF]
ENERGY T-24❑
I Y[] N[J
❑ Certified copy is hereby furnished.
Certif cop is led �y; iidi to tilt inspection division.
Apple:... _C •
MISC.- REFER TO ORD.
Cli RTIFICATE OF .XEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
C04ENSWION INSURANCE
(This SecTidn need not be completed if the permit is for one
V No
V N�
PLG. CONTH. LIC. NO.
PLG,
TOTAL
hundred dollars (S 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
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE 1'0 APPLICANT', II', after making this Certificate of Ilx
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
emotion, 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.
AIR HANDLING UNIT (TO 10,000CF.M.) 4.00
AIR HANDLING UNIT (OVER 10MC.EM.)6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that Olen is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the Penton ntaBoa of the work for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT (OV ER 100,000 B.T.U.)9.50
ELECTRIC
I certify that I have read Ihis application and stale that the above
VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER- COMP(3 H.P. or 100,000 B.T.U.1 6.00
BOILER-COMP (Ovar 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby oullmnrepresentatives o
ves this city to enter upon the
m
above-entionaed proopertyerty inspectionlbrpurposes. '
(We) agree to Save, indemnify and keep hurnless the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs unit expenses which
may in any way accrue against said City in consequence of the
gr 1lrlgofnhiipermll. QMECH.
I 1, 10
PERMIT ISSUANCE 10.00 '
CONST. TAX
CONT. LIC. NO. MECH.
TOTAL
TOTAL
Ignaturc of Appli ant/Contractor Data,
OFFICE COPY