13243 (2) o
T_
APP,'�!CANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
to Ir BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT ,
ADDRESS � � FQIrwOOA <- Ct _ 13243
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
O NERS PLAN CHECK VALIDATION
" E QTY. ELECTRIC PERMIT FEE
C S PHONE
CONTRACTOR's UTLETS'-SWITCHES-RECEP 10.00/1.00
N E p
'✓•-T IS LIC.No. LISS 0 LIGHTING FIXTURES 10.00/1.00
cONTRACTORs PPLIANCES-RESIDENTIAL 4.00
ADDRESS
Crl. (rS Jr4 PRONE � {� PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMPI 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AARCH OR DDRESS ENG. - SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION
a is w I hereby affirm that 1 am licensed Under provisions of Chapter 9 ISSUANCE DATE
,e a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H n z Professions Cod a d my license is in full(ar a J ec ❑ ❑ ❑
z 0 wt - Licenu Class L Lic.Numbepp
0 m -CDate Conlreaorr
r 3 BUILDING PERMIT
Be c w OWNER-0UILDIiR DECLARATION INFORMATION
E
0 H I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
3 u •� VALUATION $/FT.
H u o a Law for the following reason.(Sec.703 I.S.Businexsand Professions PERMIT ISSUANCE 10.00
Code:Any city or Lvunty which rtquirn a permit tD cons(mcl,alleq
re a, <o improve,demolish,or repair any structure,prior to Its issuance,also EIEC.CONTR. LIC.rv0. ELEC.
- 0,
requires the applicant for such permit to File a signed statement that TOTAL PERMIT TO
whe is licensed pursuant to the provisions of the Contractor's License q�
H z i 4aw(Chapter 9(commencing with Section 7000)of Division 3 of the rf
-a Business end Professions Codc)or that he is arempt therefrom vnd QTY, PLUMBING PERMIT FEE
athe basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a by any applicant for a permit subjects the applicant Ora civil penalty ALTER-DRAIN VENT-WATER (EA.) 5.00
of not more then five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC,GROUP RES.UNITS
their Sole compensation,will do the work,and the structure 6 not
intended or offered for sale (Sea 7044, Business and Profession, DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Codc: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 5-007L) SOLFT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such I improve- I GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 meats are not intended or offered for sal,If,however,the building
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4(EA) 200
builder wdl have the burden of proving that he did not build or ire - . .
- . BUILDING USE
prove for purpose of wk.). INDUSTRIAL WASTE INTER30.00 RES IND CON PB Omer
Cl .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 or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. - ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 1FsmA 5.00 ACC.DATE ACC.FILE NO.
WORK Ii RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
thereby affirm that I have a certificate of commrl to sclf-insure. 11�1
or a certificate of Workers'Compensilion Insurance,or a certified ZONING ENG.SITE NO.
copy them f((Sec 38QQ,Lob.C6 Q i s'
Policy Na.Vf96{Tlcreby I". -
�❑/Certified copy is ereby furnished. r L,1 Qt 1a er rr
Z 2 sH Certify� copy i; file�d with (h �1y ins[Lact�on division. 1i FIRE SPR INK ENERGYT Id,
O Applicant s%,TONS 'I LL{nY %NF MISC- REFER TO ORO. Y❑ N❑ Y❑ N❑
CC PERMIT ISSUANCE 10,00 FLDODZONE A.L.U.c.
LU CERTIFICATE OF EXEMPTION FROM WORKERS'ILS COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLG. /! Y❑ N❑ Y ❑ N❑
D Z (This section need not he completed if the permit is for one TOTAL
hundred dollars(5100)or IessJ
U O 1 cortify that in the performance of the work let which this per- Q". MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not enlploy any person in any manner OR as to
0 W become subject to the Workers mof Copensation laws Catif.,nm
LU Dat° Applicanl ALTER'OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex_
♦- ? emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you trust forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNMOVER IO=CF.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
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Address ELECTRIC
. 1 certify that 1 have read this application and slate(hal the above VENTILATION FAN (SINGLE) 4.00
information u correct. I agree to comply with all city and county PLUMBING (�
ordinances and state laws relating to building construction, and BOILER-COAT I3 H.Ror100,000B.T.U.) 6.00 /�/ `J
hereby aulhorme represenlalivu of this city to enter upon the BOI LER-COMP tOv ,11X,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 end expenses which CONST.TAX
may in any way accrue,against said City in couce
tquenof the PERMIT ISSUANCE 10.00
grant sy of this fie L MECH.CONT. LIC.NO. MECH.
M �Z, -?L?I& 7 TOTAL TOTAL
Signatureof Applicant omramor Date
I
OFFICE COPY