13286 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION a PERMIT NUMBER
;I•BUILDING - , APPLICATION & PERMIT -13286
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�TEvFe B
.vs �',eeeUILDING-ELECTRICAL-PLUMBING-MECHANICAL
wrvER'S PLAN CHECK VALIDATION
NAME /� QTY. ELECTRIC PERMIT FEE
7--C v ee{ �tlo 3
corv7R c7oRs UTLETS-SWITCHES-RECEP 10:00/1.00
NAM'
LIGHTING FIXTURES 10.00/1.00
C NT ActORs APPLIANCES;-RESIDENTIAL 4.00
AD .S
�+ V r ,PHONE PANELS 16.00 PLAN DATE CHE OF APPLICATIOP C.NO.
PRO ECT x - PANELS (OVER 200 AMP)-„ 20.00 -
Oa p
E OR
SIGNS TRANS. .3.00
ARCR.OR ENO./ 5.66 PERMIT VALIDATION
ADOREss - SPECIAL CIRCUIT ,
EMP.METER OR POLE INS. ,20.00
APPLICANT'$ - MOTORS, SEE FEE SCH.
ADDRESS
•• SERVICE CHANGE 20.00 ! ' "'�"•
w0 o LICENSED CONTRACTORS DECLARATION. ` rl - 19x8 •. -
a o U, I hereby affirm that I am licensed under prtobik,ia of Chapter 9 ISSUANCE DATE
y a (commencing with Section 7000)of Division 3 of flic Business and 1 r• T. - PLG. MECH.
H w z Irrofessions Cod yl Wicense is in full fo t}•jfjy:LJ7 ❑ It til ❑
Z O w - License Class (/ Lic:.NumberJW�fy_�2Cf18rl
Q H w I)o1c � Contracirn�L e
a�Y /C BUILDING PERMIT
.et.a w ¢ OWNER-BUILDER DECLn RA I' N INFORMATION
E: 0 MISC.- . REFER TO ORD
.W 3 u. I hereby affirm that Poet exempt from the Contractor's License VALUATION
u0 ¢ „ Law for the following reason.(Sec.7031.5,Businessamd professions PERMIT ISSUANCE 10.00
� - Code:Anycity orcounty which rerjuiresa perm i t toconstri,taller,
at a, Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. - LIC.NO. ELEC.
aa - O LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
P_ w m he is licensed pursuant to the provisions of the Contractor's License- f-
�iQLawI(Chapter 9(commencing with Section 7000)of Division 3 ofthe' r .
i O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE 1
ICH the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
e- by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).);
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,andahe structure is not _
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner Of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA -TOTAL ACREAGE
himself or through his own employees,provided thin such notionvC GAS-EA.SVSTEM-11NC.40UTLET$ 6.00
meats arc not intended or_nffered for sale.If,however„the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) '2.00 BUILDING USE
builder will have the burden Of proving that ha did tint build or Int- "
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB oche,
O I,as owner of the Property,.am exclusively contracting with ❑l ❑ ❑' ❑ I❑
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 ,
10 an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmctor(s)licensed pursuant to
the Contractor's License Law.' SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.,
O 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 ACO.FILE NO.
�Wp)iR F C IpryE�u I LIG/C�.n RATION WATER TREATING EQUIP. 5.00
I her-O",li tr E�ta/e a jly: consent
to self-insure,
( a cert ifica e o Workers'CompellSation nsumnce,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company -
�/PP MA�N<
Q ❑ Certified copy is hereby furnisheA. ��U/a)Q � FIRE SPRINK ENERGY T-24
_z_ 2 ❑ Cerlilmd c y is de with the •ly mspenion division.
❑ - Applicant MISC.- .REFER TO ORD. : Y ❑ N❑' •, Y ❑' N❑
to t PERMIT ISSUANCE .. 10.00 FLOOD ZONE A.L.U.c.
CC Cli I' Ilam-.O PT} OIt S' ,
LL,f'>` COM :NSATIO SURANCIi PLG.CONTR. - LIC.N0. PLG.
d 0 (This sectiiin need riot be'c pleted if the permit is for one ' TOTAL Y❑ - N❑ V❑ N❑
Z) Z hundred dollars($100)carless.)
V 0 1 certify that in the performance of the work for which this net- FEEFEE FEE SUMMARY
F mil is issued, t shall not employ any person in any mannei 50 as to
DTV. MECHANICAL
0
U become subject to the Workers'Compensation Laws of California.
- w Date Applicant - ALTER OR ADD TO MECH. '5.00 BUILDING
} H NOTICE'f0 APPLICANT: If,-after making this Certificate Of Ex-
H Z emption,you should become subject to the WOrkeri 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 tanned revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction letulitig agency for EXHAUST HOOD(WITH DUCT)- 5.00 -
the Performance of the work I' which this permit is issued(Sec. MICROFILM
3097,Civ,C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
^ Lunderi Name '� -/✓ - HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Addre .�'.-
1 certify that I have read this application and state that the above - VENTILATION FAN (SINGLE) 4.00
®� infnnnution is (cornet. Degree to comply with all city and County BOILER-COMP(3 H.P.or 700,000 B.T.U.) 6.00 PLUMBING
ordinances and state Izws 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 io save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino agai at liabilities,judgments, costs and expenses which - CONST.TAX
may in y uy c' a against id City in consequence of the -PERMIT ISSUANCE 10.00
gr of p i . MECH.CONT. UC.NO. MECH.
TOTAL TOTAL tj-
Signatim,of Applic t Cont or Date .1
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FFICE COPY