13825 APPL CNTT IL I F N WITHIN RED LINES - USE BALL POINT PEN ONLY
ILDIN PROJECT I DENTI FICATION PERMIT NUMBER
i
BoAPPLICATION APPLICATION & PERMI
ADDRE
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 13825
OWNER'S !/ PLAN CHECK VALIDATION
"aMEai+GJ D CITY. ELECTRIC PERMIT FEE
PHONE
CONTRACTOR'S OUTLETS-SWITCHES-RECEP 10.00/1.00
aME /
i- ry /`EuC.NoLIGHTING FIXTURES 10.00/1.00
f-ONTRACTORs
ADDRESS ,Sk,)-,,4 CMr/. pPLIANCES-RESIDENTIAL 4.00
Jf1r� ONE y ,0J/ PANELS 10.00 DATE OF APPLICATION
aRCNITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK fEE P.C.NO.
OR
ENGINEER
LIC.No. ISIGNS TRANS. 3.00
ARCH.OR ENG. 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
2,P TEMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGEF,-"-i.' 20.00
o o LICENSED CONTRACTORS DECLARATION O ✓/P- /' A/ SForf��`-'- �0 J
a u v 1 hereby affirm that 1 am licensed under provisions of Chapter 9 i' "'Al Fa ISSUANCE DATE
H <N (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
H N z Professions Code�an�d'my,l.i.c,ense is in full force a flet[ =z ❑ ❑ ❑
0 i m o License Class-�a=Lic.Number
2 w H j Date�J._!�<-Contractor QAL_ /� ll•]
ff/oflr � �Vl/jor BUILDING PERMIT
Ix w < OWNER-BUILDER DL'CLARATION INFORMATION
E
LL h I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
g Businessand Professions VALUATION
F LL o a Law for the following reason.(Selz 7031.5, PERMIT ISSUANCE 10.00 ,�
Code'.Any city or county which requires a permit to construct,alter,
re u,<IO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC,NO. ELEC.
O e requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A w m u- he is licensed pursuant to the provisions of the Contractor's License
Fit Law(Chapter 9(rommencingwith Section 7000)of Division 3 ofthe G
14 c Business and Professions COde)or thut he is exempt therefrom and DTV. PLUMBING PERMIT FEE
EE o the basis for the alleged exemption.Any violation ol'Section 7031.5 STORIES TYPE CONSTR.
T 12 by any applicant for a permit subjects the applicant oa civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(SS00)J:
❑ 1,as owner of the property,or my employees with wages as IBACK F LOW PROTECT.DEVICE 4.00OCC.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,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
. property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.0050.FT.FLOOR AREA TOTAL ACREAGE
himself or through his awn employees,provided that such improve- GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
ments are not intended or offered for sale.If,however,the building
or impruvemem is solA within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIALWASTE INTER. 30.00
D 1,as owner of the property,am exclusively contracting with
licensed contractors to construct tile project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00r_ ASSESSORS PARCEL NO.
and Professions Code'.The Contractor's License Law docs not apply
to an owner of property who builds or improves Dmreon,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 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under See. .B.&P.C.for this WATER HEATER W/VENT 6.00
Oon
wner Dam WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure. zoNING ENG.SITE NO.
or a certificate of workers'Compensation Insurance,or a certified
copy thereof(See.3800,mLab.0 4
Poy'cY No. Copany
,f�setlified copy is hereby furnished. FIRE SPRINK ENERGY T24
Z Z Cl .`rutted copy isfiled with Else cit�specti,n division. MISG- REFER TO ORD.
Applicant �_ ���L P - V N V N
cc y 'CER'T'IFICATE 01:17XEMPI'ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD zorvE A.LU C.
LU 2! COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. V N� V NEI
o (This section need not be completed if [lie permit is for one TOTAL
Z) Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work lin which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,1 shall not employ any person in any nnom r eo as to
O w become subject to the Workers'Compensation Laws of California BUILDING
Dale Applicant ALTER OR ADD TO MECH. 5.00
>- DO NOTICE TO APPLICANT; 1f,after making this Certificate of I>x-
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 permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency I'or EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
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 BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)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 mid expenses which CONST.TAX
may in any way accrue against said Cily in consequence of the PERMIT ISSUANCE 10.00
granting of this permit MECH.CONT. LIG NO. MECH.
TOTAL TOTAL
Signature of Ap cant/C ntraclor Dade
OFFICE COPY