13892 APPLICANT TO FILL IN INFORMATION-;�IVf'THIN RED LINES - USE BALL POINT PEN ONLY
6J LO NL;PROJECT 1 DENTI FICALION - PERMIT NUMBER
muLmNG - / APPLICATION & PERMIT 13892
AgpRESS, "' BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
I IAE) SA -Su.�w AGE fL0
OWNERS PLAN CHECK VALIDATION
NAME
OTY. ELECTRIC PERMIT FEE
T PHONE
CONTRACTOR
NAME UTLETS-SWITCHES-RECEP 10,00/1.00
tV N -
E IC.No. LIGHTING FIXTURES 10.00/1.00
ADOREAcroRs PPLIANCES-RESIDENTIAL 4.00
D IDa-1.-ue.I`2.r1T,$.3 PHONE0W-qPANELS 10.00 DATE OF APPLICATION
ARCHITECT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
UC.No. SIGNS TRANS. 3.00
ADR. ENG. SPECIAL CIRCUIT 5.00 �iw� VALIDATION
ADDDRESSSS
zIP EMP.METER OR POLE INS. 20.00
APPLacANT' LY////LC CG GA MOTORS SEE FEE SCH. ( pp
ADDRESS l it , ,. O , . //•, r/1
SERVICE CHANGE 20.00 6 .{
wo o LICENSED CONTRACTORS DECLARATION _ II� OI Cupertino
1 U u I hereby affirm that I am licensed tinder provisions of Chapter 9 ISSUANCE DATE
w <w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. Over.
r D 2 Professions Cods•,,an rt�y license is in full lure a eel ❑ ❑ ❑
E, 02 - Llcen Clnss `- O Lie.Numhcr
4 w w Uale Contractor S2C2f.]?9
¢ r " BUILDING PERMIT
rc ¢ w ¢ OWNER-BUILDER DECLARA I INFORMATION
-A o o ° REFER TO ORD
X
LL h I hereby affirm that I am exempt from the Contractor's License M ISC.-
LL o ¢ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION SIFT.
- 0 ` Code:Any city or county which requires a perm it to construct,alter,
ac ¢a p improve,demolish,or repair any structure,prior to its issuanc0.nISO ELEC.CONTR. LIC.NO. ELEC.
O M requires the applicant for such permit to file a signed statement that TOTAL PERMITTO
'x $ he is licensed pursuant to the provisions of the Contractor's License
r 2 r
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ Imo-o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ; by any applicant for a pennit subjects the applicant toacivilpenalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 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 thereon,and who docs such work FIXTURES,PER TRAP 5.06 SG.FT.FLOOR AREA TOTAL ACREAGE
himself or through his awn employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
D I,as owner of the properly,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 of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projectswith a contractors)licensed purso:mt to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC FILE N0.
woRKGRS'Co NS I ��Y�/f.p/(��R]I���fON WATER TREATING EQUIP. 5.00
1 hereby elf a I ova au c L YltlllSefll to selGlnsom,
or a certificat of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
co Py
thereof Sec.3800,Lab.C.). •�,�-� ,�..��s/�pper�„„��,,�/�.
Policy No. Company pC!/leE�r�
O ,0 Certified copy is hereby furnished FIRE SPRINK ENERGY T�24
Z Z y- Certi o is �I�1 ve the InSpycNon division.
O Applicant�G.' Oi/l� MP/ . wG�-[� MISC.- REFER TO ORD. Y❑ NO
Y ❑ No
CC rn PERMIT ISSUANCE 10.00
� - CERTIFICATE COMPENSATION
OF ION EXEMPTIONFROMWORKERS' FLOOD ZONE A.L.U.C.
W 7 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Z( This section need not be completed if the permit is for one TOTAL v❑ N❑ Y 11 ON 1:1
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H our is issued,I shall not employ any person in any nmnner so as to
U become subject to the Workers'Compensation Laws of California.
0 i
Date-Applicant OR ADD TO MECH. 5.00 S - BUILDING
} rn NOTICE TO APPLICANT: If,after making this Certificate Of Ex-
H ? 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.M.1 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the h7C. nce of the work for which this permit is issued(See. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
IsnJer's Name HEATING UNIT(OVER 100,000 B.T.U.)B.50 LI C
Lender's Address E ECTR
ir-
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree lO comply with all city and county PLUMBING
ordinances and state laws relating to 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
bov.-Owntmited property for inspection purposes. BOILER-COMP (Over 100,000 BTU)BEE FEE SCH. MECHANICAL DO
a
(We) gra o ve, indemnify and keep harmless the City of MISC.- REFER TO ORD.
CupW o a n liabilities,judgments, costs and expenses which CONST.TAX
may ' a
at against said City in consequence of the PERMIT ISSUANCE 10.00 IQ�
gra 1. permit. -^JoLY/�./Lf CH.CO LIC.NO. ME H.
r �G 2 � �'Y�IRE T oL TOTAL fi
iijignaturc of Ap Icant/Contractor Date GpL Z' .d /1 ,
OFFICE COPY