13148%APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - E BALL POINT PEN ONITA6
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�• BUILDING PROJECT 1 DENTITa ION
BUILDING
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APPLICATION & P MIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
13148
OWNER'S
Z&J / �j y ] h,!5I,/�/l.'
iT/Y/�'
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTOR
(J�^�
�1 O %l/ Co � LOC No {„tom �
OUTLETS -SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1,00
co TRACT s
A SS Y �/�1`-J'�/r
Ox 0 PHONE
PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00
ARRCH IT ECT ! / / �a 31�
/y" .f
ENGINEER
LIC. No.
PANELS (OVER 200 AMPI 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENG.
SPECIALCIRCUIT 5.0Q
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
. ZIP
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
�-'0 rl/-•`--7`J
LICENSED CONTRACTORS DECLARATION
'
I hereby affirm that I am licensed under provisions of Chapter 9
(Commencing with Section 7000) of Division 3 of the Business and
Professions Cod - rydAlTlicense is in full force )d
License CIS LLVV Lic. Number
ISSUANCE DATE
-
BLDG.
ELECT. I
PLG. I MECH.
❑
Date_ Contractor
BUIL
INFORMATION
- OWNER -BUILDER DECLARATION
I hereby affirm (but I am exempt from the Contractor's License
Law for the following reason.(Sec. 7031.5, Business and ProfessionsPERMIT
Code: Any city or county which requires a permit to construct, cher,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division'3 of the
Business and Professions Code) or that he is exempt therefrom and
-
MISC. - REFER TO ORD
ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTR. LIC. NO. ELEC.
TOTAL
DTV. PLUMBING PERMIT FEE
PERMIT T
47,044
STORIES
TYPE CONSTR.
the basis forthe alleged exemption. Anyviolation of Section7031.5
by any applicant for a permit subjects the applicant toa civil penalty
of not more than five hundred dollars (5500).):
ALTER-DRAIN&VENT-WATER IEA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered fm sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds orimproves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. l f, however, the building
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -11INC. 46UTLETS Q00
or improvement is sold within one year of completion, the owner.
builder will have the burden of proving that h e did not build or inr
prove for purpose of sale.).INDUSTRIAL
❑ 1, as owner of the property, am exclusively contracting with
- GAS - EASYSTEM -OVER 4 IEA.) 2,00
.
BUILDING USE
RES IND- CON.' PB Omar
❑ ❑ ❑ ❑ ❑
WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
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- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contra ctons) licensed pursuant to
the Contractor's License Law,
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO,
PARCEL NO.
❑ I am exempt under Sea ,B.&P.C. for this
WATER HEATER W/VENT 6.00
reason
Owner Dale
WATER SYSTEM 5.00
ACC. DATE
ACC. RLE NO.
WATER TREATING EQUIP, 5.00
WORK ERS'COMPENSA'I'ION DECLARATION
I hereby affirm lhffi I have a certificate of consent LLr self-inxum,
�000rrr a certificate ofWorkers' Compensation Insurance, o a certified
mpany
ZONING
ENG. SITE NO.
FIRE SPRINK
Y❑ IN
ENERGY T-24
Y❑ No
II Itereby famished.
1 ertlfied copy is filed with the city inspection division.
App scant
MISC- REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOODZONE
A.L.U.C.
COMPENSATION INSURANCE
('Phis section need not be completed if the permit is for one
PLG. CONTR. LIC. NO.
PLG.
TOTAL
Y ❑ IN
Y ❑ IN [J
^^
QTY. MECHANICP015 MIT FEE
s
FEE SUMMARY
hundred dollars ($ 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ :my person in any mmnner so as In
BUILDING
become subject to the Workers' Compensation Laws of California
Date Applicant
ALTER OR ADD TO MEC 1 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10 %-fi 4.00
AIR HANDLING UNIT dittk ffl=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.CJ.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Names
HEATING UNIT (OV ER 100,000 B.T.U.) 9.50
ELECTRIC
Lundcr's
VENTILATION FAN (SINGLE) 4,00
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and slate laws relating to building construction, and
hereby authorite representatives of this city to enter upon the
above-mentioned property for inspection purppses.
PLUMBING
BOILER- COMP 13 H.P. Or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
p
•��
(We) agree to suvc, indemnify and keep''ffharnrlcss the City of
Cupertino against liabil' les, judgments, costs and expenses which
may in way Be against �sid City in cureeyuence of the
gran ll0 O( -pent L D _ f
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO. MECH.
/� �f Q TOTAL 00
AM (/GD ,Z 3 35
TOTAL
Signa(ur Applicant/Contractor Dole
OFFICE COPY