13370 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 13370
A ORE
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
NER'a PLAN CHECK VALIDATION
"AME OOTY. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS
N E OUTLETS-SWITCHES-RECEP 10.00/1.00
N� uc.N 30 LIGHTING FIXTURES 10.00/1.00
CCINTHACTOO/I�QlJfhe. PPLIANCES-RESIDENTIAL 4.00
ADDRESS NW�Pw
PHONE PANELS 10.00 DATE OF APPLICATION
OR_
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER LIC..No. � SIGNS TRANS. 3.00
AENG. PERMIT VALIDATION
ADDRESS DOn[ss� SPECIAL CIRCUIT 5.00
Q-w
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS
S �O I�J MOTORS SEE FEE SCH.
ADDRESS =![,'fr(�•'-' "
&A q5)ZIi5 SERVICE'CHANGE 20.00
'09 LICENSED CONTRACTORS DECLARATIONLa
a U L, I hereby affirm that 1 am licensed under provisions of Chapter J ISSUANCE GATE
FA Q aw (commencing with Section 7000)of Division 3 Df the Business and BLDG. ELECT. Phi MECH.
N z Professions Cody my license is Nin full for / �11 I,�p� ❑
z o w - Licens Class Lic. gI
amber- L_ IuU Y
0 L r w SV
Datc_ �2,eei Contractor - L
BUILDINGPERMIT
a w u OWNER-BUILDER DECLARATION INFORMATION
woA. - MISC.- REFER TO ORD
LL H I hereby affirm That 1 um exempt from the Contractor's License VALUATION S/FT.
F u o¢ Law for the following reason.(Sec.703 L5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,Ater, !-0-,C2 al¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. J�
w o u 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
R z
>-
Law(Chapter 9(commencing with Section 7000)o f Division 3 of the
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
1- $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u5_ by any applicant fora pemtit subjectsthe applicant toa civil penalty �' ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their Sale compensation,will do the work,and the structure is not
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 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsare not intended oroffered for Sale.If,however,the building GAS-EA.SYSTEM-i INC.4 OUTLETS 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 im BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB oma,
❑ 1,as owner of the property,am exclusively contracting with ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- NC6.00 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 SPRINKL R�9°- ER 5 IEA.I 1.00
contracts for such projects with a contractors)licensed pursuant to
the ntmetor's License Law. SEWER-SANITARY.ST 200ft/l Q00 TRACT NO. PARCEL NO.
I am Il a fyi"a�,B.&BC.for this
reason
I� '(!�j WATER HEATER dW/V EN'T 6.00
Owner _ Date WATER SYST M'- e(L\ 5.00 ACC.DATE ACC,FILE NO.
WO 'I:RS'COMPF.NSA'I'ION DECLARATION WATER TREATI O'EOUIP, 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec 3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished.
FIRE SPRINK ENERGY R24
Z Z ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. y [3N[] v � N�
CCy CERTIFICATE OP EXEMPTION FROM WORK F RS' PERMIT ISSUANCE 10.00 O FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTE, LIC.NO. PLG.
d O . (This' section need not be completed if Be permit is for one TOTAL �J Y❑ N❑ Y❑ N
Z hundred dollars IS IOD)or less.)
V O 1 certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ a y S�n � to Obecol�v�y�cs Workers CoI 'a .Ow Date./SF 3JApplicant_ - BUILDING
a L ALTER OR ADD TO MECH. 5.00N NO'fICF: TO AI'P ICAN'T: If,a mr nmk' Ex-
emption,you should become subjec oon APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
L) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER I0,000GEM.) 6.00 SEISMIC FEE sf�
I hereby affirm 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. HEATING UNIT(TO 100,000 B.T.U.) 8:00 MICROFILM
3097,Civ.C.). `
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 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-COUP(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 property for inspection purposes..
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino Agai liabilities,judgments, costs and expenses which - CONST.TAX
may in ap��
rue against said City in consequence of the PERMIT ISSUANCE 10.00
grantinMECH.CONT. -LIC.NO. MECH.
Lzo1 TOTAL TOTAL
Signoratracmr Date
It F OFFICE COPY