14262 4 PPLICANTJO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
• BUIrDING PROJECT IDENTIFICATION APPLICATION & PERMIT
,( BU IAOOmENG L� 14262
aooREss(� 1� Sam SjL'CI L/6- 21� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OwNER'S `7 "� J`l is VRe PLAN CHECK VALIDATION
"a("�"E[� Q (� rL ELECTRIC PERMIT FEE
c(�fiI)CEHEZ LV l,"Q-•�JPHONE
CONTRACTORSp UTLETS-SWITCHES-RECEP 10.00/1.00
r NAME p
�/1 �4Go.AT-IQS ECSC( 11.N1,3? G(03 LIGHTING FIXTURES 10.00/1.00
nooAEssro((IIR��s / aa��-II Oxy Ue APPLIANCES-RESIDENTIAL 4.00
71/7Z{)^%0OV�-S AI/E P"✓ PHONE 2LJ^^�eb PANELS 10.00,20- DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIc.NO. SIGNS TRANS. 3.00
ARCH.OR ENO SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANrs
ADDDRESSDRESS MOTORS pAIREFEESCH.
e- SERVICE CHANGE 20.00 p�
o o LICENSED CONTRACTORS DECLARATION / a
W.sHj I hereby affirm that I am licensed under provisions of Chapter 9 //(SSU ANC DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG, ELECT. PLG. MECH.
Fu Professions Code,It, mY6cen Li is in fall r"Cwd.e(feV.3 s-.,• ❑ ❑
z o= License Clas t- Lic.Number J (J 4 Ir-VYI
9 L r w Uale II� �B Conlrodor� C 1�
P: us Lar!-`IL BUILDING PERMIT
¢ , OWNER-BUILDER DECLARATION INFORMATION
waA � MISC.- REFER TO ORD
3 LL H I hereby affirm that 1 em exempt from the Contractors License VALUATION $/FT.
FUNJLaw for the following reason.(Sec.703L5,Business and Professions PERMIT ISSUANCE 10.00 Qf�
Code:Any city or county which requiresa permit toconstrucl,alter,
C40 improve,demolish,Or repair any structure,prior 10 its issuance,also ELEC.CONTE. LIC.N0. ELECIS .
IS
requires the applicant for such permit to file a signed statement that TOTAL
w 2 w he is licensed pursuant to the provisions of the Contractors License PERMIT TO
H Z rt Law(Chapter 9(Commencingwith Section 7000)of Division 3 oflhe T
Business and Professions Code)or that he is exempt therefrom and CITY. t PLUMBING PERMIT FEE EL'��'C/
¢ r D the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ; by any applicant fora permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
Clem more than five hundred dollars(S500)J:
❑ I,as owner-f 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,GOND. 5,00
Code:The Contractors License Law does not apply to an owner of
• property who builds m improves thereon,and who does such work FIXTURES-PER TRAP 5,00 SO,FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.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-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have lite burden of proving that he did not build or im. RES IRO CON PB Ohne,
❑ 1,as owner of the properly,am exclusively Contracting with ❑
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
11 13 ❑
licensed contractors to 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
1 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 cool ractorts)licensed pursuant to
the Contractr's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exoempt 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.
v/ WORKERS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP. 5.00
U 1 hereby affirm that I have a certificate ofconsent to self-insure,
3 f or a certificate of Workers'Conhpenealion Insurance,or a certified ZONING ENG.517E NO.
of lScc.3800,Lab C.). Svr 2tilV'r-'U,L'('f°•'
Policy No. Company
rs tied copy isl reby fur the • FIRE SPRINK ENERGY T-24
Z Z Certified npy filed with insh Cron division.
U Applicant � �... MISC.- REFER TO ORD. v ❑ NO v ❑ N❑
~ w PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
CE RTIFIC OP EXEMPTION FROM WORKfiRS'
LU - CONIPENSATION INSURANCE PLG.CONTR. ❑C.NO. PLO,
IL Cl (This section need not be Completed if the permit is for no ' TOTAL Y❑ N❑ Y❑ N❑
Z) Z hundred dollm,0100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I. mit Is Issued, I shall not employ any person in any mannerso us to
U become subject to the Workers Compensation Laws of California.
0 LU Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N 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 perrdit shall be deemed revoked. AIR HANDLING UNIT(TO 100OOC.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING 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
3097, i
er performance U
ance of the work for which this permit is issued(Sec. HEATING NIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address H EATI N ELECTRIC
G UN IT(OV ER 100,000 B.T.U.)9.50
• I certify that l have no,,this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon Ilse BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We)-agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino againsl liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any wayaccrue agai Id ty ' consequence of the
grant Is a, MECH.CONT. LIC.NO. MECH.
` TOTAL TOTAL
Signature f plicanl/Contractor Date
{u OFFICE COPY