13627 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BILI LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
HUILOIN APPLICATION & PERMIT 113627
Aoo Ess
w BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
DINNERS - PLAN CHECK VALIDATION
• " QTY. ELECTRIC PERMIT FEE
HONE
CON RCTOR'a '
' N M L+_� OUTLETS-SWITCHES-RECEP 10.00/1.00
� LIGHTING FIXTURES' 10.00/1.00
CONTRACTOR'a - pPLIANCES-R DENTIAL 4.00
t,,YCA(AN PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS IOVrER12Q0 AMP) 2000 Ot PLAN CHECK FEE P.C.NO.
LIC.NO. SIGNS TRA 5;3
ENGINEER (� _. 3.00
ARCHOR ENG.Hl - SPECIAL CIRp IT S,OO - PERMIT VALIDATION
ADDZIP EMP.METE1%R P L O 20.00 Pa
AAPPLICADDRESS MOTORS SEE FEE SCH. f/
SERVICE CHANGE 20.00 [� F o
- I5K H v l
woo LICENSED CONTRACTORS DECLARATION � `/1 r /y
M U w I hereby affirm that I am licensed under provisions of Chapter 9 .— S(` 2 Q, Q` 4(/ ANCE DATE �� 7
(commencing with Section 7000)of Division 3 of the Business and BLDG. PLG. MECH.
D i Professions C-de�n icense is in full force a e ecF, , ❑ ❑ ❑
z o y— License Class LIC.Number Y _ D•a
9 w l-w Date Con me _Vt_L r,1—501 H _ J
a y ��. 3r, b ICL. 6 LAD&� as BUILDING PERMIT
0w ftA
OWNER-BUILDER DECLARATIO INFORMATION
x ;u 1- 1 hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO ORD VALUAT ON S/FT.
P.o j Law for the following reason.(Sec.7031.5,Business and Professions pER 17 ISSUANCE 10.00
Code:Any city or county which requiresa permit loconstrucl,eller,
Q G o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i —o w requires the applicant for such permit to file a signed statement omt TOTAL - p gMIT TO
K
$ he is licensed pursuant to the provisions of the Contractor's License
tz i Law(Chapter 9(commencingveith Section 7000)of Division 3 ofthe r
Q Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
It=$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
[heir sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
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 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-I 6.00
ments are not intended or offered for sale.If,however,the budding
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 he did not build or im- RES IND CON P9 Om.,
for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,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 Cade.The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a contruchms)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10,00 TRACT NO. PARCEL NO.
the Contractors License Law.
❑ I am exempt under Sec.—,W&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
I hereby affirm that I have a certificate of consent to sell'-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy there (Sec.3800,Lub.C.). y
Policy No. 00— Company—C"+a_rJ 0N->
0 ❑ Certified copy k hemby furnished. FIRE SPRINK ENERGYT-24
Z Z )<Certife copy��z�yyyys filed the ' y Inspection division. MISC.- REFER TO ORD. y N y q
Q Appltcan t �' ❑ ❑ ❑ ❑
~ vi PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
� CF.R IFICCOM COMPENSATION
ION FROM WORKENS'
CL _ COMPENSATION INS ! PLG.CONTR. LIC.NO, TOG. Y❑ N F1 Y[:] N❑
1 D (This section need not he completedd if if thethe permit is for one TOTAL
0 Z hundred dollars(5100)or less.)
L) O I certify that in the performance of tire work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL — not is issued,I shall not employ any person in any manner so as to
0 W become subject to the Workeri Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} (6n NOTICE TO APPLICANT: If,alter making this Certificate of Ex-
F.. Z 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
(� 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 10=C.EM.) 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
Lender's Name
Lender's NameAddress HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC 5�
I certify that I have teas this application and state thatthe 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 construction, and (3 BOILER-COMPH.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city m enter upon the gO1LER-COMP IDVar 100,000 BTU)SEE FEE SCH. 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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue•against id City in consequence of the
gr ng of this p it. MECH.CONT. LIC.NO. MECH.
Z--, � TOTAL TOTAL
St Deter, Applicant/C ntractor IDale
OFFICE COPY
ADDITIONAL PERMIT FEES
BUILDING PROJECT I DENTI FICATION VALUATION
aooaai
111t7143
NEfl'S
/b jd 3 WJdlZ.Fc SCD
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NAME
WILT �J �&, FEE SUMMARY
caxTaAcrOas }
NAM �i BUILDING
LIP
' Q
r✓M MfTK.�f- � c.No T PLAN CHECK
:ooniss TOa' FEE
`5 >xo.E '171/ SEISMICFEE
OTU.
/ ELECTRICPERMIT FEE
5��PPLIANCES-R7ESJDENTIAL
SWITCHESAINS.
ELECTRIC �'S_du
IXTURES
PLUMBING
S-RESIDMECHANICAL
NS. TOTAL
RCUITR OR POPERMIT VALIDATION
MOTORS . �1
SERVICE CHANGE
Z z
LO OTAL
ISSUANCE LATE
lL >_ OTU. PLUMBING PERMIT FEE BLDG ELECT. PLG. mete.
U O ALTER-DRAIN&VENT-WATER(EA.)LL _—_ __ ❑-- ❑ ❑ ❑ ,
BACKFLOW PROTECT.DEVICE
O W DRAIJJS-FLOOR,ROOF,AREA,COND.
Y n. FIXTURES-PER TRAP
N
�— Z GAS-EA.SYSTEM.1INCA OUTLETS
(,) GAS-EA.SYSTEM-OVER 4(EAl
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B.
LAWN SPRINKLERS-OVER 5(EA.)
SEWER-SANITARY-STORM EA.200f1/
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP.
TOTAI
OTU. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE
AIR HANDLING UNIT(TO 10=CF.Kx
AIR HANDLING UNIT(OVER 10JAOC.F.M.)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.)
HEATING UNIT(OVER 100,000 B.T.U.)
VENTILATION FAN(SINGLE)
BOILER-COMP(3 H.P.Or 100,000 B.T.U.)
BOILER COMP(0-1100,000 BTU)SEE FEE SCH.
TOTAL