13071 (2) AP.P.LICANT TO FILL IN INFORMATIO VITHIN RED LINES - USE BALL POINT PEN.ONLY
•` i WILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
I BU DING O'T-3
AOOr+EssT1480'CFQZSAi_I AN ._LOT 3 13071
!- � _ -�. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
NAME PLAN CHECK VALIDATION
@� CITY. ELECTRIC PERMIT FEE
S PHONE �J
NAMERACTOR's It LA ZZ&J OUTLETS-SWITCHES-RECEP 10.00/1.00
k't, LIC.No, LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S ` PPLIANCES-RESIDENTIAL 4.00
RCRRECTQ
ZI rPHONE 9 - ,J PANELS 10.00 DATE OF APPLICATION
ORPANE-S (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
ELIC.NO. SIGNS TRANS. 3.00
ADORES ENG. SPECIAL CIRCUIT 5.00 PERMIT q VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 PA
ADDRESS Ts - MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 J�
Foo LICENSED CONTRACTORS DECLARATION ts7,/ ��.F;Ino
a v v I hereby affirm that I am Bcensed under provisions of Chapter 9 ISSUANCE DATE
rt a. (commencing with Section 7000)of Division 3 of the Business and
BLDG. ELECT. PLG. MECH.
r i Professions Code,a my license is in full fore nd effect. ❑ ❑ ❑
Zo m o License CI s Lic.Number
r _ r J Date Contractor
w a OWNER-BUILDER DECLARATIO BUILDING PERMIT
- o A u INFORMATION
X ; u r- 1 hereby affirm that I-am exempt from the Contractor's License MISC.- REFER TO ORD
u0 Law forth,following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
r N a g PERMIT ISSUANCE 10.00
f Y2 improve,
A,demol or corn lywhich structurep riorft toconsuance,aur.
S Q Q D improve,demolish,or repair any structure,prior n its issuance,also ELEC.CONTR. LIC.NO. /
ELEC.
a. -O I[ he
the applicant for such permit ns file i signed statement that TOTAL PERMIT TO
F
m u he is licensed pursuant to the provisions of the )o Contractor's License
r i at Law(Chapterand
Professions
or
is exempt
therefrom
3 and
the
sQ Business and Professionsxemption that Anyviis,xem pf ection70and CITY. PLUMBING PERMIT FEE /
=$ the basis for the alleged enemplion.-Any violation of Section 7031.5
a ; by any applicant for a permit subjects the applicant toa civil penally STORIES TYPE CONSTR.
of not more than five hundred dollars($500).): &
: ALTER-DRAINVENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 occ.GROUP REB.urvlTS
their sole compensation,will do the work,and the structure is not
intended or offered for safe (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 p
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 SD.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 33 PZl
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the properly,am exclusively contracting with ® , El ' El El C3
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 or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 36rZ
contracts far such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORMEA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Seo.,B.&P.C.for this
reason WATER HEATERW/VENT 6.00 79
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 NO.
copy thereof(Sec.3800,Lab-C.).
Policy No. Company 11 S�`e �/\fl s� ALI O
0 ❑ Certified Copy is hereby furnished. FIRE SPRINK -ENERGY LY4
Z Z G�Cerlified c s filed ith the i inspection division. -
F O Applicant --r»/t MISC.- REFER TO ORD. Y [3 NQ Y [] NE]
CC CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.c.
W COMPENSATION INSURANCE PLG.CONTR. LIC.No, PLG.
1 (This section-need-not be completed if the permit is for one TOTAL Y❑ N� Y[] NLI
D Z hundred dollars IS 100)or less.)
L) O 1 certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
ly 1- mit is issued,I shall not employ any person in any manner so as to
V become subject to the Workers'Compensation Laws of California.
0.WDate Applicant BUILDING S7l
>_ W NOTICE TO APPLICANT: If,after making this Certificate of Ea- ALTER OR ADD TO MECH. 5.00 7/0
FZ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK '
provisions of the Labor Code, you must forthwith comply with 1
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,00011F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.RM.) 6.00 SEISMICFEE 71
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this7 permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
• I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4,00
information is correct. 1 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, anJ
hereby authorize representatives of This city to enter upon the BOILER-COMP IDVBr 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. p
Cupertino against Babilities„judgments, costs and expenses which' CONST.TAX
may in any way accrueMIT ISSUANCE 1000
,against said City in consequence of the PER . v
granting lh' permit. MECH.CONT, LIC.NO. MECH.
�� TorAL TOTAL /Sym7
Signature of App' t/CGntractrr ale
OFFICE COPY