13429 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON - PERMIT NUMBER
BUILDING APPLICATION & PERMIT
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 13429
OwNEERRR'S qAy ,ZPCK VALIDATION
kle ":AETQ� - O TY. ELECTRIC PERMIT - FE
/�� �CJTT/l '✓1 PNONE�C_J ! O
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00 �i 19
/n� �1 ,, ///� /J�7Q 94
LQ YT�L/G� l..Q'V[Lllc.No
! /0,3 LIGHTING FIXTURES 10.00/1.00
C-ONNTTRACTOR'6 �-y� /)1?0P-C7+4/ l� /LC- PPLIANCES-RESIDENTIAL 4.00
ao 2&5-a LJ PANELS 10.00 DATE OFF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE I ,P.C.NO.
OR
ENGI"EER SIGNS TRANS. 3.00
NO.
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION •/`�
2 u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y< (commencing wI Section 7000)of Division 3 of the u;i ss and BLDG. ELECT. PLG. MECH.
H O i Professions Cod ,Ingecr se is in full forcoC�
z O w License I s Lie.Number /// !!!
9 m w Date - Contractor
x s w BUILDING PERMIT
IC u OWNER-BUILDER DECLARATION INFORMATION
F.
;n H 1 hereby Briton that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
� u.oJ Law for the following reason. 7031.5,Business and Professions PERMIT ISBUANCE 10.00 VALUATION $/FT.
�w0 Code:Anycity or county which requires a permit to construct,alter,
a a, ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
u xO u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
$ he is licensed pursuant to the provisions of,the Contractor's License
_ ii Law.(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe r
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT I E
Fi0 n
H$ the basis for the alleged exemption.Any violation of Section 7 penalty '! I !,- R E CONSTR.
n ;� by any applicant fora hundred
vmbjcds th5000.)cantfoacivil penalty ALTER-DRAIN&VENT-WATER (EA-)'6,0
I
of not more than flue hundred dollars(my em: 1
❑ Las owner at the property,or my employees with wages as BACK F LOW PROTECT.DEVICE J O .yR RES.U ITS
their sole compensation,will(S the work,and the structure is not �If
intended or offered for Luce (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CO D. 5. 0
Code:The h o builds or improves
License Low does not apply o an owner of
+ arm
property who builds or improves thereon,and who dues such work FIXTURES-PER TRAP 5. _ _so.RR.RLOOR AREA -T eAGE
nests are otintndugh e ownemployees,for sale.
If,
ed thal however
himprove- GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
meats are not intended sold or offered for sale.IL however,the building
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM.OVER 4 (EA.) 2.00 BUILDING USE
Owner-
builder will have the burden of proving that he did not build or im RES IND CON PB Other
prove for purpose of sole,)' INDUSTRIAL WASTE INTER. 30.00
❑ d as owner of the property,he exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors Cod to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code The Contractor's License s d does not apply
to tr owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for suchicenL -SANITARY-STORM EA. .00e with n coNracmrts)licensed pursuant m SEWER 200ft/10
the COptaf S License Law. TRACT NO. PARCEL NO.
❑ lain exempt under Sec.-,R&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.,
WORKERS'COMPENSATION DECLARATION WAT R TREATING EQUIP. 5.00
1 hereby affirm that I have n cerci de ubwnsenl to self-insure, ZONING ENG.SITE N0.
ce�rYf�fl t�ypp or r MC/t�1 n In��/Q'rnn�ec�or,a�cur/}hfie
' Ywr/ mL
Q ❑ Ce ed copy .is here by furnished, FIRESPRINK ENERGY T-24
❑ rtifie cogsdsled wit 01• yty inspection division.
Z2 /Pt 1l /1 MISC.- REFER TO ORD.
O APP icant .T��CwTI�I Y ❑ N❑ Y ❑ N❑
CCN CE RTI F ICATE OF EX EMPT ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL o (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ No
D Z hundred dollars(S100)of less,)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I. mit is issued,I shall not employ any person in any manner so as no
OW become subject to the Workers'Compensation Laws of California.
tl Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT: II',after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCEPLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U' such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,000QF.M.
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M. 6.00 SEISMIC FEE
1 hereby affirm than there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
thelperform3097,Civ.C.�oce of the work for which this permit is issue)(See. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
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 than the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating no 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 10var 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep armless the City of MISC.- REFER T ORD.
Cupertino a atom liabilities,judgme nos, cos nnJ expenses which CONST.TAX
may in u y accrue,against said Cit in asequence of th PERMIT ISSUANCE
gran ng permit. /s ��- MECH.CONT. LIC.N0. MECH.
/.1 i �n] ��{{A'')Q/� TOTAL �Qi TOTAL
Signal of pplicant/ ontractor Dare TI�� ✓L ! [V3
OFFICE COPY -