13177 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
RUILDING
a0 R ss
• t- C e 1I BUILDING —ELECTRICAL—PLUMBING—MECHANICAL 13177
OWNER'5 L• PLAN CHECK VALIDATION
N"ME '/J OTY. ELECTRIC PERMIT FEE
E „ Q/f/ PHONE
-GrvTRADTG 's
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NIT 61-77 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS �/ U APPLIANCES-RESIDENTIAL 4,00
A;;j O ryCIjp�/rf
PANELS 10,00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE
OR
ENGINEER
I.C.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
zHP EMP.METER OR POLE INS. 20.00
APPLICANT's MOTORS SEE FEE SCH. n
ADDRESS
SERVICE CHANGE 20.00 /ry
o o LICENSED CON'T'RACTORS D13CLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
G a LDG. ELECT.m (commencing with Section 7000)of Division 3 of the Business and - BPLG. MECH.
r om Z cene:Professions Cotjj-au lise is in full farc �e f•ety O ❑ ❑
z O w — License I`ss Loc.Number /
o m lto Date Contractor
¢ se s BUILDING PERMIT
¢ w u OWNER-BUILDER DECLARATION INFORMATION
aO> MISC.— REFER TO ORD
X. g LL N 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
HUOJ Law for the fallowing reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to constn¢L alter,
¢ 2 Q improve,demolish,or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O¢ requires the applicant for such permit to file a signed statement that TOTAL
ERMIT TO
u w$ ho is licensed
Hf u4 O pursuantrho provisions ofthe ia Law(Chapter (commencing Section )ofDivision 3 License
Q /a
Business and Professions Code)or that he is exempt therefrom and
OTY. PLUMBING PERMIT FEE
¢ H by basis for the alleged exemption.Any violation t tSection malty STORIES TYPE CONSTR.
by any applicant fora permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-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,tend 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 does such work FIXTURES-PER TRAP 5.00 SG.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such in.prove-
meets are not intended or offered forsale.If,however,the building GAS-EA.SYSTE 11N OUTLETS 6.00
or improvement is sold within one year of completion,tire owner- GAS-EA.SVSTE -OVER 4 (EA.) 2.00
builder will have the burden of proving that lie did not build or un- - BUILDING USE
prove for purpose of sale.). INDUSTRIAL AST INT R:jl 30.00 RES IND CON PB Other
❑ 1,as owner,of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contmctor5 to construct the project(Sec. 7044, Business LAWN SPRINKLERS-`7 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions co ,:d 'file Contractor's License Law does not amply
to an owner of property who builds or improves thereon.and who LAWN SPRINK E S-OV�Ft1 .'(. .) 1.00
contracts for such projects with a cantractor(s)licensed pursuant to SEWER-SANITA -STORM EA.200ft/10.00
the Contractors License Law. Q TRACT NO, PARCEL NO.
❑ l ante exempt under Sec. ,BAP.C.far this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 S' ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSAT'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to sell-insure, ZONING ENG.SITE NO.
or a certificate o Wor Densat ion Insurance,or n certifinl
copy tilerpts�( Q
Policy Nd"r Company SOri'�FIO.Q � Tieyit'
O ❑ Cei-ifiedcopyPh ere fm
by nlflled, FIRESPRINK ENERGY T-24
Z Z ❑ Certified copy is Bled with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
CC y PERMIT ISSUANCE 10.00 Q!
Ir CERTIFICATE COMPENSATION
INS PROMWORKERS' FLOOD ZONE A.L.U.C.
W > COMPIiNSATION INSUIiANCIi PLG.ODNTR, LIC.NO. PLG, � 7
d a I (This section need not be Completed if the permit Is for one TOTAL / �C Y❑ IN Y❑ N❑
=)Z hundred dollars IS 100)or lco.)
L) O 1 certify that in the performance of the work I'or which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person on any manner so as to
(] w - become subject to the Workers'Corupensa tion Laws of California. BUILDING
y Date Appl¢ant ALTER OR ADD TO MECH. 5.00
} m NOTICE TO APPLICANT': IL after making this Certificate of Ex
2 eruption,you should become subject to lire Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith cmnply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10/100C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE
1 hereby affirm that there'is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the 3097,performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address - ELECTRIC
I certify that I have read this application and state trot the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-(bMP(3 H.P.OF 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes
(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 said City in consequence of the
gem ' goflhos ern' . MECH.CONT. LIC.NO. MECH.
TOTAL - TOTAL
agnature Applicant/Contractor 'Dale
OFFICE COPY