13253 'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION &'PERMIT
ly ADDRESSlo� Rimevee c 13253
vel BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER PLAN CHECK VALIDATION
NAM P QTY. ELECTRIC PERMIT FEE
F_rgoL.
PHONE
"CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
o
x KE sec,NO LIGHTING FIXTURES 10.00/1.00
/
CONTRACTOR sPPLIANCE6-RESIDENTIAL 4.00
\CRS C g7vL' PANELS 10.00 DATE OF APPLICATION
ARCRITECT PANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C.NO.
OR
E NGINEE F
LIC.No. SIGNS TRANS. 3.00
"ARCH.OR ENG. SPECIAL CIRCO IT 5,00 PER MIT VALIDATION
ADDRESS
ZIP EMP-METER OR POLE INS. 20.00
APPLICANT's MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 Imo, J/fi
au
o o LICENSED CONTRACTORS DECLARATION
a I hereby affirm (hat I am licensed under provisions of Chapter 9 .. ,. ISSUANC&DATE
a<y (Commencing with Section 7000)of Division 3 of the Business and 'BEDG.j ELFtCT. / PLG. MECH.
F 7 i Professions Co and my license is in full for - of I. ❑ ❑ ❑
z z y - Licen Lic.Number
_o I- Unte Contracmr
t'7 ':rBUILDINO PERMIT
= w u
OWNER-BUILDER DECLARATION INFORMATION
E
3 LL vHi 1 hereby affirm that 1 am exempt from the C'ontractor's License MISC.- REFER TO ORD
a. D < Law I'or the following reason.(Sec,7031.5,Businessand Professions PERMIT ISSUANCE 10.00 `/ALUATION S/FT.
� - Code:Any city or county whichrequiresa permit loconstruct,alter.
<O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR.
LIG NO. ELEC. /
to
D , reunites the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w8 he is licensed pursuant to the provisions of the Contractor's License
HiQ La..(Chapter 9(commencing with Section 7000)ofDivision 3 of(he V�d�/cJQ /v(/rE
4 o BusPLUMBING PERMIT FEE
ness and Professions Code)or that he is exempt them and QTY.
2 H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d5,: - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars(3500).):
O 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole 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 Ihercon,and who docs such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himselfor through his own employees,provided that such Improve-
mentsarenotintended or offered for It.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, (ht owner GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON Ps Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with
licensed contractors 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 Law does not apply
to an owner out property who builds or improves Ihercon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractogs)licensed im"mnl to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ l am exempt under Sec. .R.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACGDATE ACC.FILE NO,
WORKIiRS'COMPIiNSA'TION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm (hut I flute a cenilicxle of consent to sell-in,,urc, 20NING ENG.SITE NO,
or a certificate of Workers Compensation Insurance or a certified
copy(herein See.3800,Lab.C.).NeMC�N5t7RhFY,
O Policy No. Company_
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z r� Centile c y 01 w I the I pc 'U li " MISC.- REFER TO ORD. y N Y 0 NC]
P0 npplicant_AL��j�7lir-L
CC L2
CE RTI 11 OIr EXEMPTION FROM WORK ERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W 7 CObIPFNSATION INSURANCE PLG.CONTR. LIC.NO, PLG. Y❑ N� YF] N�
d 0 YThis action need not be completed if the permit is for one TOTAL
D Z hundred dullars($100)car less.)
U O I certify that in the perfonn:mce of(he work far which Ihis per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to -v
(] W become subject to the Workers'Compensatiou Laws of California. BUILDING � a
Date Applicant ALTER OR ADD TO MECH. 5.00
} ai NOTICE'I'O APPLICANT: If,after making this Certificate of Ex-
Z 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 permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirms that (here is a ronstruction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which(his permit is issued(See HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATINGUNIT(OVER100,000B.T.U.)9.50 ELECTRIC
Lender's Address
-
I certify that l have read this application and state that tile 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-COMPI3 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 BTUI SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against suit) City in corse rice sf the PERMIT ISSUANCE 10.00
of of this MECH.CONT. LIC.NO. MECH.
6a i�--¢__ S7 TOTAL TOTAL
ignaNrc of Applicant°/Contractor•^ ale
OFFICE COPY