13586APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL -PLUMBING- MECHANICAL
PERMIT NUMBER
13586
BUILDING
AOOREss
)01 GWE51hi ILC _ O
OWNER'
NAME
OTY, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHONE
CON
NAME RACTORS
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
&IWNA
IC.NO. L
CONTRACTOR'S
ADDRESS
APPLIANCES - RESIDENTIAL 4,00
PANELS 10.00
HONES
PATE OF APPLICATION
ARCHITECT
OR
ENGINEER
LIC. NO,_
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
AARCH. OF DDRESS ENG.
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
ZIP
ADDRESS -
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 run licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code n I m license is in full force ml jjyrG
License Class Lic. Numbe L%4.i
ISSUANCE DATE
BLDG.
❑
ELECT,
❑
PLG. MECH.
❑
Dale C�ntrador ��r LNtM-G hM
BUILDING PERMIT
OWNER -BUILDER DECLARATION
1 hereby affirm that I mn exempt from the Contractor's License
Law forthe following reason. (See. 7031.5. Business and Professions
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, of repair any Structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
therefrom and
Business and Professions Code) or that he is exempt therefrom and
INFORMATION
IMISC. - REFER TO ORD
VALUATION
E/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIQ NO.
EL EC.
TOTAL
PERMIT TO
OTY. PLUMBING PERMIT FEE i
OTY. PLUMBING PERMIT
STORIES
'• TYPE CONSTR.
the basis for the alleged exemption. Any violation of5ection 7031.5
by any applicant for a permit subjects the applicant toacivil penalty
of not more than five hundred dollars (5500).):
ALTER -DRAIN & VENT -WATER (EA.) 5.00
' ❑ 1, as owner of the property, or my employees with wages as
their sale compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GHOUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
Property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. l4 however, the building
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - 1 1 NC. 4 OUTLETS 6.00
Or improvement is sold within one year of completion, the owner-
builder will have the burden of proving (list he did not build or im.
prove 1, aso nee of sale.),
❑ as owner of the properly, exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
he
licensed contractors to construct the project (Sec. 7044, Business
d
and Professions Code: The Contractor's License Law does not apply
to anowner of property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS -OVER 5 (EA.) 1,00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Lew.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO,
PARCEL NO.
C I am exempt under See. ,B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO,
WORKERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE N0.
copy thereof (Sec. 3800, Lab.C.L
Policy No. Company
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.
Applicant
FIRE SPRINK
Y C]N ❑
ENERGY T-24
Y C]N[]CERTIFICATE
MISC.- REFER TO ORD.
EEE
OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE,
A.L.U.C.
PLO. CONTR. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE.
(This section need not be completed if the permit is for one
Y ❑ N ❑
Y ❑ N ❑
QTY. MECHANICAL PERMIT FEE
,
FEE SUMMARY
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this per.
is issued, I shall not employ any P rson in any manner an as to
eco!tbj#VtL cWelkeri m e ation Laws of Califomia.
in
Date_2L 4 Y-PJApplicant e+1LQeFe-�
BUILDING
.00
ALTER OR ADD SO-MECH. 5.00-
NOTICE TO APPLICANT: , sfter making thFs Certificate of Ex-
APPLIANCE - 5.00
PLAN CHECK
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked
-
AIR HANDLING(UNIT_'ITO 10,000GF,M) 4.00
FEE
AIR HANDLING UNIT(OVERr10pdOC.F.M.1 lit
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
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.
3097, CN.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00 rf•
HEATI NG UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
Lender's Name
NameAddress
Lender's
1 certify that 1 have read this application and state that the above
VENTILATION FAN (SINGLE) 3-4.00 (Z,
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMPI3H. Ror100,000B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU I SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
ahove-mentioned property for inspection purposes.
MISC. - REFER TO OF
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way acc a against said City in consequence of the
grantln (Isis per .
tl
CONST. TAX
PERMIT ISSUANCE 10.00 0
MECH. CONT. LIC. NO. MECH.
TOTAL 34
TOTAL
Sig eof Applicant/Contra mr Date
OFFICE COPY