13176 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
4 BUILDING PROJECT I DENTIFICATION"r - PERMIT NUMBER
BU'DING APPLICATION & PERMIT 131 ER
i ADDRESS
SEE pF BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
76
WNER'g O PLAN CHECK VALIDATION
. NAME OTY. ELECTRIC PERMIT FEE
LJ�' r e / PHONE
NAME croR UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
/GCEf�// b/l/ Llc.No. LIGHTING FIXTURES 10.00/1.00
r.Nrnacroms PPLIANCES-RESIDENTIAL 4.00
,oOREss n/ /
oz3o �ff'E G`PHONE /�Lp PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 FLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENc' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP, TEMP.METER OR POLE INS. 20.00 _K
APPLICANT S MOTORS SEE FEE SCH.
ADDRESSooREss
SERVICE CHANGE 20.00 1_///
/ /
O
'02 LICENSED CONTRACTORS DECLARATION N(//7/ d-7
a v u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
way (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Hoz: Professions Co urd y license is in full fore• e f t. ❑ ❑ ❑
O i=o Licero
nse lass _V _Lic.Number
F m r J Ua[e Contractor
¢ y s BUILDING PERMIT
¢ m < OWNER-BUILD17R DECLARATION INFORMATION
o A MISC.- REFER TO ORD
K
; u r I hereby affirm that I con exempt from the Contractor's License VALUATION $/FT.
a_ a. Law for the following reason(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
� N0 Code:Any city or county which requires a permit to construct,alter,
2 2 Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
c LL requires the applicant for such permit to file a signed statement that TOTALac PERMIT TO
a as
he is licensed pursuant to the provisions of the Contractor's License
Fi�'
Law(Chapter 9(Commencing with Section 7000)of Division 3 ofthe LBG
¢ Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
sio
¢ H $ the basis for the alleged exemption.Any violation t to a cion malty STORIES TYPE CONSTR.
a ; by any applicant fora permit dollars S500).licam toacivil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred Dollars(8500).1: '
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00
their sole compensation;will Jo the work,and the structure is 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
property who buil,,or improves thereon,and who does such work FIXTURES-PER TRAP 5,00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building
or imProvemeal is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 IEA.) 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 PO Other
tr
❑ I,as owner of the properly,am exclusively conacting with El ❑ El ❑ 13
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 0yERs (EA.) 1.00
contracts for such projects with a contractorts)licensed pursuant to SEWER-SANITARY-STORM EA.,200ft/10.00
the Contractor's License Law. L TRACT NO. PARCEL NO.
reason
Ownerlam exempt under Sec. ,BAP.C.for this WATER HEATER W/VtENT ut ~)`7" 6.00 6
Owner Date WATER SYSTEM
,{ S ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING Ip. 5.00
1 hereby affirm that I have a ccrtif tate of consent to self-insure, ZONING ENO.SITE NO.
or a certificate of Workers''CC pensalion Insurance or a certified
copy d e2;y� p..� ,,ROL (
Policy NdW_ I n+nP�
cupanY
Q ❑ Certified Copy is hereby furnished. FIRESPRINK ENERGY T-24
Z 2 ❑ Centric c Is f d the y inspection division.
O Applicant A `SyS ,.Ory.If�/ MISC. REFER TO ORD. Y [] NE] Y ❑ N[]
CCw CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 0) FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
.' O (This action nee, not be completed if the permit is for one TOTAL �� Y❑ N❑ Y❑ N
D Z hundred dollars($100)or loss)
(„) O I certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued. I shall not employ any person in any manner so as to
OW become subject to the Workers'Compensation Laws of California.
0. Date Applicant BUILDING
} N NOTICE TO APPLICANT: If,after making this Cert ifica le of 1:x- ALTER OR ADD TO MECH. 5.00
F ? sorption,you should became subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=QF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER ig000C.EM.) 6.00 SEISMIC FEE
I hereby affirm 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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.)8.50
Lender's Address ELECTRIC
• I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and cuddly 'PLUMBING (f
mdoonces and state laws relating to building construction, and BOILER-OOMP(3 H.P.Of 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE SCH, MECHANICAL
(We) agree to Save, indemnify and keep harmless the City of MISC. REFER TO ORD.
Cupertino against liabilities,judgments, costs andexpenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in coo erryence of the
gram); permij,/ �x� MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature of Apppliccant Contractor Date
OFFICE COPY