13826 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJ CT I DENTI FICATI ON PERMIT NUMBER
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�� �Uo�F6 APPLICATION & PERMIT 13826
ADORE s
li _ BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
ONNNElik5 PLAN CHECK VALIDATION
. NAME 1,
( PHONE CITY. ELECTRIC PERMIT FEE/U �
croRs
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
NAME Gp
Q j. l29 Ill.No. ! Z LIGHTING FIXTURES 10.00/1.00
CONTRACT O� APPLIANCES-RESIDENTIAL 4.00
ADDRESS
L(� �• 5,7 ONE /-/ -ZI // PANELS 10.00 DATE OF APPLICATION
ARCHITECT I PANELS (OVER 200 AMP) 20.00PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
zIP EMP.METER OR POLE INS. 2000
TSCH. ^
APPucarvr's MOTORS SEE FEE
ADDRESS
SERVICE CHANGE ""20.00
F D o LICENSED CON'T'RACTORS Uf:CLARATION V ��"`
<v U I hereby affrro that I am licensed under provisions of Chapter 9 p / Lf, [.� (� ISSUANCE DATE
v, <w (commencing with Section 7000)of Division 3 of the Business and O BLDG ELECT. PLG. MECH.
H w z Professions Codea,a�J rp license is in full for d eifel{. ...._eft]n ❑
z o.A - License Class /xwJ Lie.Numbe Ea '7' PL- ` i V "Vu'S' ❑ ❑
Q z: r w Date � / / t:J- Contrudor 5f -
a v,s ED ��/-a�f`T �.y BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARA'1'I RFS INFORMATION
v REFER TO ORD
w3 o. m 1 hereby affirm that I am exempt from the Contractor's License MISC.- VALUATION S/FT.
to .. oJ Law for the followingreason.(Sce,7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
6 ¢Q 0 improve,demolish,m repair any structure,prior to its issuance,also ELEC.CONTR, LIC.NO. ELEC. 9Q
- O ec requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contr:mtor's Liense
HiQ
Law(Chapter 9(commencing with Section 7000)of Division T-1f t he
4 c Business and Professions COLIC)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ;m 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:
❑ I,as owner of the property,or my employees with wages as IBACK FLOW PROTECT.DEVICE 4.00 Dce.GROUP REB.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 a Li ccns'e Luw docs 11,11 1111Y 10 an,1wncl 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 that such improve- GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
ments aro not intended or offered 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 he did not build or im- RES IND CON PB Omer
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 1:1 11 ❑ ❑ ❑
❑ I,as owner of the property,am exclusively contracting with
licensed cmdroclors 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 or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractods)licensed pursuant to SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a Certificate of consent to tell-insure, ZONING ENG.SITE NO.
or a Certificate of Workers'Compensation Iosurance or a certified
Copy thereof(Sec.3800,I.A.C.),It'�M,�p..� -
Policy No. Company
O QL Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is til ith tI;Aty inspection division. MISC.- REFER TO ORD. y N Y ❑ N❑
H O Applicant 'F 7� 7� � - ❑ ❑
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE
� y
Lid > COMPENSATION INSURANCE PLG CONTR. LIC.NO. PLG. Y[_ N❑ Y ❑ NC]Q (This section need not be completed if the permit is for one TOTAL
0 Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per-r-
I
MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,I shall not employ any person in any manner sO as to
OPV become subject to the Workers'Compensation Laws of C.1donma. BUILDING
Dam Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT': If,after making this Certificate of Ex-
f'- ? ensption,you should become subject to the Workers CompensationAPPLIANCE 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(TO 10fMC.F.M.) 4.00
CONSTRUC'T'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
hereby affirm that there is a construction lending agency forEXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lenders Address
30
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
imormasioo is correct. 1 agree to comply with all City and COlary BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby au lludee representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEESCH. MECHANICAL
abovomentioned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liab' lies,judgments, Costs and expenses which CONST.TAX
may in any way ac ue again end City in consequevue of the PERMIT ISSUANCE 10.00
granting of this per MECH.CONT. LIC.NO. MECH.
� c7
TOTAL TOTAL
Signature of Applican/Contractor Date
OFFICE COPY