13088 ,NT TO FILL IN INFORMATION WITHIN RED LINES -,USE BALL POINT PEN ONLY
,JI LDING PROJECT IDENTIFICATION PERMIT NUMBER
.,NG APPLICATION & PERMIT 13088
sou'a5
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OwNFR'S PLAN CHECK VALIDATION
NAME E�YYP� DTV. ELECTRIC PERMIT FEE
PHONE��(�
PCONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
Ir O LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00 "
AGOREss
IgnONE,Aa�26q PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.O.NO.
O
OR
NGINFER
ICD�G.ND. C 5 87 SIGNS TRANS. 3.00
ARCH.OR RENG. C' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
EEL ) C) �apqf46Z rrEMP. METER OR POLE INS. 20.00
AooPPucarvr's MOTORS SEE FEE SCH.
aREss
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION
v I hereby affirm that 1 am licensed under provisions o f Chapter ISSUANCE DATE
G w (commencing with Aection 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
z Professions Code, my license is in full for ❑ ❑ ❑ ❑
i0_ - License Claap}s _Lic.Number_f.3'/✓c1
o Z r na Da[e_a_1��7 Contractor
y BUILDING PERMIT
a w u OWNER-BUILDER DECLARA'ITON INFORMATION
ion MISC. REFER TO ORD
X 3 LL H 1 hereby affirm that I am exempt from the Contractor's License ATION $/FT.
1- 0 4 Law for the following reason.(Sec.703 L5,Business and Professions PERMIT ISSUANCE 10.00 Q�
Code:Any city or county which requires a permit to construct,alter,
aca ¢ FO , improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. O Ems' 1 n IIy-
i w m LL requires the applicant for such permit to file a signed statement that TOTAL rLLf RMITIO
he is licensed pinpont to the provisions of the Contractor's License
r z a
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe 'rL!� :1
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FE�'tY
1I
$ the basis for the alleged exemption.Any violation of Section 7031.5 TYPE CONSTR.
a3 by any applicant for a payout subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
O I,as owner of the property,or my employees with wages as BACK FLOW PROTECTDEVICE 400
their sole compensation,will do the work,and the structure i . .
s not OCC.GROUP RES.UNITS
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
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
Burls are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.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 im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB omar
❑ I,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I 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 for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA,200f1/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,IL&P.C.forth's WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORK GRS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a cerlil'ied
T' copy there yy�� Lob-CI OL_.'� '�`�-�� 1
Policy No. Y- : many- CZ>_VdUA
0 ❑ Certified copy ishereby furnished. FIRE SPHINK ENERGY L24
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
~ w PERMIT ISSUANCE 10.00
LU CERTIFICATE COMONSATIOT ION FROM WORK IiRS' FLOOD ZONE A.L.U.C.
W � COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL Z( This section need not he completed if file permit is for one TOTAL Y❑ IN E] Y ❑ N❑
hundred dollars(S 100)or less.)
L) O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any tanner so as to
O W become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} tp NOTICE TO APPLICANT: If,after making this Certificate of Es-
? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must Ibrthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
t CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perfo3097. rmance of the work for which this permit is issued fSec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATI NG UN IT ER 100,000 B.T.U.)9.50 3Q
Lender's Name
ELECTRIC
��
• I certify list I have read this application and slate thin 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-COMP(3 H.P.Or 100,0008.T.U.) 6.00
hem-by authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE PEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgme 's, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may In an way accrue agalna, so
Clty in consequence of the
graining is part it. MECH.CONT. LIC,NO. MECH.
1�11TOTAL TOTAL
Signaazo of Applls:anl Con lr. Dat
OFFICE COPY