13413 'N'/APPLICANT TO F LL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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NGPR J TIDENTI FICA O - PERMIT NUMBER
APPLICATION & PERMIT
A
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 13413
PLAN CHECK VALIDATION
TY. ELECTRIC PERMIT FEEOUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.N . LIGHTING FIXTURES 10.00/1,00
PPLIANCES-RESIDENTIAL 4.00
i PHO ,� PANELS 10.00 DATE OF APPLICATION
OOflcHlrecr PANELS 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3,00
ARCH.OR ENG. SPECIALCIRCUIT 5.00 PERMIT VALI CATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
W& ZP ICAN 's MOTORS SEE FEE SCH. PAM
SERVICECHANGE 20,00
WJUL �
oo � LICENSED CONTRACTORS DECLARATION z '
SC v u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m a w (commencing w L Section 7000)of Division 3 f the Busi sad R E j j1 G. MECH.
H m z Professions C e, license Is In full for ❑
z O w - License lass Con Number
w r w Date Conlracmr_
m a n OW R UILDER DECLARA I BUILDING PERMIT
o d U INFORMATION
A,
3. LL r 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
H .. 0< Law forthe following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter,
Q u,Q p improve,demolish,or repair any structure,prior to Its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
i 0, requires the applicant for such permit to file a signed statement that TOTAL _PERMIT TO
w $ he is licensed pursuant to the provisions of the Contractor's License - '
H z i Law(Chapter 9(commencingwith Section 7000)of Division 3 of the
2 o Business and Professions Code)or that be isexempt therefrom and CITU. PLUMBING PERMIT FEE r 'G/
Icr $ thebasis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ; ^ by any applicant for a permit subjects the applicant toa civil penally
of not more than five hundred dollars(S500)J: ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,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,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
• property who builds or improves thereon,and who does such work FIXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenot intended or offered for sale.l f,however,the building GAS-EA.SYSTEM-11 NC.4 OUT LETS'6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or am- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RE5 IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cbde: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
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO, PARCEL NO.
❑ l am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
reason
r - Date WATER SYSTEM 5.00 ACC:DATE ACC.FILE NO.
VRS COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate of consent to self-iosme,
or a certificate of Workers'Com e ' n Insurapce a art and ZONING ENG.SITE N0,
copy thereof(Sec.3800,Lab.C. l///VI
Policy No. Company
O ❑ Certified copy is hereby f JFIRE$PRINK ENERGY R24
Z Z ❑ Certified Co Is B it ciq inspection division.
O Applicant - MISC.- REFER TO ORD. Yo N❑ Y ❑ N❑
W CERTIFI .OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
L 7 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ v [:] N[_
Z hundred dollars(S 100)or less.)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
Q_ Date Applicant BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of fix. ALTER OR ADD TO MECH. 5.00
? 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 peril shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,OODC.FM.) IS= SEISMIC FEE
I hereby affirm that there is a construction leading agency for EXHAUST HOOD( TjH '"ICT)
5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT IT 00,000 B.T.U.) 8.00
Leader's Name HEATINGUNIT ER 100;000B.T.U.19,50
Lender's Address LECTR IC
I certify that I have read this application and slate that the above VENTILATION. N•
(SING LE) 4.00
information is correcL I agree to comply with all city and county PLUMBING ?
ordinances and stale laws relating to building construction, and BOILER-COMP(3 .Off100,BB B:(pU.1 6.00 �J �
hereby authorize representatives of this city to enter upon the BOILER-COMP 1 ger 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property to pec tion purposes.
(We) agree 1 save, em fy and keep harmless the City of MISC.- REFER TO ORD.
Cupertino ag liabili es, " dgmeats, costs and expenses which NST.TAX
may i ny ace had
Said City in consequence of the PERMIT ISSUANCE 10.00
g in of s Pe M .CONT. LIC.N0, MECH.
TOTAL n TOTAL �
S no of Appli ant/Cont elor Uate
OFFICt COPY