13694 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING ^��I
APPLICATION & PERMIT 13694
ADDRESS - BUILDINGELECTRICAL-
O"NNER'S PLAN CHECK VALIDATION
"AME TY. ELECTRIC PERMIT FEE
ke-�� PRGN �a-59
CONTRACTORS 1doUTLETS-SWITCHES-RECEP 10.00/1.00
NAME /1�' �1
LIC.No.�v,J d-- LIGHTING FIXTURES 10.00/1.00
nooeEss '�.F lyr
APPLIANCES
4.00
O �/ �U ��I !�' PANELS 10.00 DATE OF APPLICATION
ARCwTECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
ORjq
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTSMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE _ 20.00 9
0 o LICENSED CONTRACTORS DECLARATION /K 7
a u v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Q y (commencing with Section 7000)of Division 3 of the Business coil - V L r , .. BLDG. ELECT. PLG. MECH.
F y i Professions C Ie,a d,ryy license is in full for(.yyj.r�( s
z 0 w- icen las a Contract.,
p�bt) ❑ ❑
2 Z H w Date Contractor s
H - - City of Cupertino BUILDING PERMIT
OWNER-BUILDER DECLARATION INFORMATION
w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION $/FT.
u. o ¢ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 �-
- Code:Any city or county which requires permit to construct,alter,
¢ ¢ ¢ 0 improve,demolish,or repair any structure,prior l0 its issuance,also ELEC.CONTR. LIC.N0. �a5
ELEC. O-
0 u requires the applicant for such permit to file a signed statement that TOTAL
PERMIT TO
w$u he is licensed pursuant to the provisions o1'the Contractor's License L
a Law.(Chapter and
Profession,
Cod )car Section is 00)exempt theion 3 and E EL
¢ the
Busness and Professions Code)or that he is exempt therefrom end OTY. PLUMBING PERMIT FEE
¢= the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
Ur by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not mom than Ove 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,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 does such work FIXTURES-PER TRAP 5.00 SQ.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 GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 I EA.1 2.00
builder will have(h .e burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with . ❑ ❑ ❑ ❑ ❑
licensed contractors m construct the project(Sec.7044,Business LAWN SPRINKLERS-1 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 contmctoris)licensed pursuant to SEWER-SANITARY-STORM EA.200ft110.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate atomism to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
ftaGg.thcreoffScc.38COmP N_b.C.)/�.� v ��
otic Company-LSLItL�
0 rtified copy is hereby furnished - FIRE SPRINK ENERGY T-24
Z 2 Certiy' d fed wi[ t y 'ns cation divisi n, -
Ap licaary-((',�1Q�/T�.� MISC.- REFER TO ORD. Y ❑ N❑ v 11 ❑ NO
� N CI!RTfFtf'?.7E:�FE OM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L � COMPENSATION INSURANCE. PLO,CONTR. LIC.NO. PLG. v❑ N❑ Y NEI11
0. Z (This section need not be completed if the permit is for one TOTAL
hundred dollars($100)or less.)
U 0 E certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY '
LL F- mil is issued, I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0 y Date Applicunt ALTER OR ADD TO MECH. 500 BUILDING
>_ � NOTICE TO APPLICANT: If,after making this Certificate of Ex .
F emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10M C.F.M.) 6,00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.CJ.
Lender's Name HEATI NG U N IT(OV E R 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 Certify that I have read this application and$late that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county - PLUMBING
Ii ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
CupeIT O against liabilities,judgments, costs and expenses which CONST.TAX
may y way ecerue_against said City in consequence of the PERMIT ISSUANCE 10.00
I f th' permit. MECH.CONT. LIC.N0. MECH.
8 TOTAL TOTAL
IlmaIn a of Applicant/COntraC Date
OFFICE COPY