14563 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' BUILDING PROJECT IDENTIFICATION PERMIT NUMBER -
BUILDdNG APPLICATION & PERMIT
.--- ' WN1 DING -ELECTRICAL-PLUMBING-MECHANICAL 14563
NAMEOWNERS PLAN CHECK VALIDATION
NAME - OT ELECTRIC PERMIT' FEE I
PRONE
CONTRACTOn'
NAME UTLETS-SWITCHES-RECEP 10.00/1.00 ('- ,
`{ O U..No. 7 LIGHTING FIXTURES 10.00/1.00
AnneHASTORS u,"i (9-IG�� APPLIANCES-RESIDENTIAL 4.00 ,
PHONE &-pv PANELS 10.00 DATE OF APPLICATION
A CHI PLAN CHECK FEE P.C.NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENO. PERMIT VALIDATION
AOOREss SPECIAL CIRCUIT 5.00
ZIP FrEMP.METER OR POLE INS. 20.00 /1 -
A ORA Ta MOTORS 0(�1/ SEE F )(/ / _
V
SERVICE CHANGE 20,00
I,o o .LICENSED CONTRACTORS DECLARATION ,,
a I hereby affirm that I am licensed order provisions of Chapter 9 1 ISSUANCE DATE
Nay fcommennng with Section 70001 of Division 3 of the Businessaml BLDG. ELECT. PLG. MECH. .
Hoz Professions Code,and my licmdse is in full Inrpy,yyl y(1'SyLy ❑ ❑
o i er
y - Licens Class Lic.Numb _
m r u. Date Contractor
y I
Ic I= st OWNER-BUILDER DECLARATION BUILDING PERMIT
- o a o INFORMATION
X 3 n N 1 hereby affirm that I am exempt from file Contractor's License MISC.- REFER TO ORD ,
u
OR:
Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION $/FT.
- PERMIT ISSUANCE 10.00 G
mm Code Any city or county which Rquiress permittoconstmct,alter,
SE
a ¢0 Improve,demolish,oCrepalf any structure,prior to its Issuance,also ELEC.CONTH. LIG.NO- ELEC. ("�
i O M requires the applicant for such permit to file a signed statement that TOTAL AS PERMIT TO
F
$ he is licensed pursuant to the provisions of the Contractor's License /
Hid Law,(Chapter 9(comencingwith Section 7000)of Division 3 ofthe
4 o Business anmd Professions Code)or at he is exempt therefrom and DTV. PLUMBING PERMIT FEE
re H c� tth
he basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to Semi penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as -
BACK FLOW PROTECT.DEVICE '4.00 OCC.GROUP RES.UNITS
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 dues such work FIXTURES-PER TRAP 5.00 so.PT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
n
nook are arc not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement is sold within one year at completion,the owner
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB One,
El 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sce.7044,business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code,The Contractor's License Law floes 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 wfuraclor(s)licensed pur owbt to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec...B&P.C.R,r this
'"sonWATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK F RS'COM PFNSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby infirm Ihat I have a certificate of consent to s'el Ginslre,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
- copy of Sec. R 0,Lab.C.
1'ol ic��om..b. �S7R11ser�I Ri'L
0 ❑ Pithc copy is hereby furnished. - FIRE SPRINK ENERGY T.24
Z 2 ❑ Certified y is rileith As city inspection division.
F 0 Applicant
0-y- /T .nsr- MISC.- REFER TO ORD, Y [] N Y Q N�
CL N CE RTI FI CAPE OI'RX EM PTI ON FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE. PLG.CONTH. ❑c.NO. PLG.
CL 0 (This section need nal be completed if[he permit is for one TOTAL Y N Y ❑ IN
D Z hundred dollar,IS 100)or less.)
U 0 I certify that in the performance of the work for which this Per FEE SUMMARY
LL F mil is issued,I shall not employ any person in any Inanner a as to OTV. MECHANICAL PERMIT FEE
U w become subject to the Workers'Compensation Laws of California. -
a Dale Applicant BUILDING
>_ 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex ALTER OR ADD TO MECH. 5.00
F'- 2 eniptlon;you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, yen most Forthwith comply will, FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby afford 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. MICROFILM
3097,Cie.C.). - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nume HEATING UNIT(OVER 100,000 B.T.U.)9.50 /��
Lender's Address ELECTRIC I
I eerily that l have road this aPpliemion:md slate that the above VENTILATION FAN (SINGLE) 4.00 ,
1 information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and 130ILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon fit
above-mentioned property for nspection purposes.
BOILER-COMP (Over 100,000 BTUI SEE FEE$CH. .MECHANICAL
i
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against ,aid City in conwquencu of the
r oI this permit MECH.CONT. LIC.NO. MECH.
\/ pu r TorAL TOTAL
�C SI na aro fAp Kant/Cor tactor etc
OFFICE COPY