13398/ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
.SMI LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
Bm DING - APPLICATION & PERMIT
// JJ 13398 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
O"N"" PLAN CHECK VALIDATION E / OTV. ELECTRIC PERMIT FEE
1i4
CO TRACTOR'S
E / OUTLETS-SWITCHES-RECEP 10.00/1.00
L � c.NO. �7/`sem LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
AO �REaS'�✓
eyp;J / PHONE �O PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ADDRESS ENc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. Q
SERVICE CHANGE 20.00Y/ 7
00 LICENSED CONTRACTORS DECLARATION
a u u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
z w' (commencing with Section 7000)of Division 3 of the Businessand BLDG. ELECT: PLG. MECH.
ZProfessions Code,�d m "en sc isS fall fort LIle�L 7 � ❑
Z o vi - Licens ass e, NumM1e J p
D 2 Dale Contract.
El
Q y s C BUILDING PERMIT
ic e w u OWNER-BUILDER DECLAR O INFORMATION
K
;' f 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u n VALUATION $/FT.
Fay Law for the following reason(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
M Code:Any city or county which.....beau permit to construct,alter,
Q a 4 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- C u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E:
51 he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)ot'Dlvision 3 oftheLa G-,
a Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
n by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
!heir sole compensulion,will do the work,and the structure is not
intended cur 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
properly who builds or improves thereon,and who does such workFIXTURES-PER TRAP 5.00 �i"'O SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsarenmintended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 p
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA) 200 BUILDING USE
builder will have the burden of proving that he did not build or am- . . .
RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ 11 ❑ 13 El
I,as owner of the property,am exclusively contracting with
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
to an owner of property who builds.r improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. .B a TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,H&RC.for this WATER HEATER W/VEN , 6.00
reason
Owner Date WATER SYSTEM r,t 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP.U k_7 5.00
1 hereby affirm that 1 have a certificate of consent to selpirso",
.r a certificate of Workers'Compe tion Insurance .r u certified n4 ZONING ENG.SITE NO.
copy there ( c.3800,Lab.C � n4
Policy Nr Q ompany
O ❑ Certified opy is hereby furnish)d. �` FIRE SPRINK ENERGY T-24
/
Z Z Certifie py Is filed w' he c' inspeetion n.
�^'[') MISC.- REFER TO ORD.
0 Applicant Y ❑ N❑ V ❑ N❑
~ sn PERMIT ISSUANCE 10.00
Lu CE TIFICCOM COMPENSATION
NSFROMWORK. S' O FLOOD ZONE A.L.u.c.
W >_ COMPENSATION INSURANCE PJP.CDNTR, IC.N PLG. 7,
7
1 O (This section need not be completed if the permit is for one Lfi �1�5 �7�5�.3 TOTAL /.� Y❑ N'❑ V ❑ N❑
Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance.f the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL U mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
y Date ApplicantALTER OR ADD TO MECH, 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate-of Ex-
? 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 ITO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000GF.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. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name HEATING UNIT(OVER 100,000 B.T,U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building conslfuction, and BOILER-COW t3 H.P.or 100,000 B.T.U.) 6.00,
hereby authorize representatives of this city to enter upon the gQILER-COMP(Over10g0DOBTU)SEE FEESCH. 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 CONST.TAX
may any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gl g of this permit MECH.CONT. LIC.NO. MECH.
7 TOTAL TOTAL
Signature of App licentlC.mo ctor Date iY0
OFFICE COPY