13265 (2) F- LI,G+f1NT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PMOJECT 1 DENTI FICATION PERMIT NUMBER
`BDILOING L�� APPLICATION & PERMIT
ADDRESS
�OC�tI1rdS °�- BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 13265
OWNERS 't PLAN CHECK VALIDATION
NAME
p�y1�` OTY. ELECTRIC PERMIT FEE
Hy CU S-4 PHONE
NAME c'ro'ny UTLETS-SWITCHES-RECEP 10.00/1.00
GTfGOe 1 uc.NrL3I {p LIGHTING FIXTURES 10.00/1.00
CONTRACTOR APPLIANCES.-PPLIANCES:RESIDENTIAL 4.00
ADORE ss (_
L PHONE 37 U PANELS 10.00 DATE OF APPLICATION
ORROHiTECr PANELS IDLER 200 AMP) ZO.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIc,NO, SIGNS TRANS. 3.00
ANC".ORDDRESS ENG SPECIALCIRCUIT S.QQ PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ANr's
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 -7// /C7
woo LICENSED CONTRACTORS DECLARATION c0
a v w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N 2 H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH,
r y Z Professions C and mY license is in full fore and effe L ❑ ❑ ❑
Zo 0 w o License Ch
'� Lie NumberUINI
Date - Curtmeor
a F :R DEC RATION
BUILDING PERMIT OWNER-BUILD
INFORMATION
X ; e- I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
¢ O Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION SIFT.
Z; Cure:Code:Any city or county which requiscsa permit toconatrucLalleq
¢ ¢ ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
a¢ rcqunes the applicant for such permit to Glc a signed statement that TOTAL I
X m he is licensed pursuant to the provisions of the Contractors License . PERMIT 1�
Hai
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe �A_/D I"3`T-eH1
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
f i o
¢ I- the basis for the allegedexam prion.Any violation of Section 703LS STORIES TYPE CONSTR.
n ; by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(S500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ 1,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 is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License taw does not apply to an owner of
property who builds or improves thereon,and who docs 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.SVSTEM-11NC.40UTLETS 6.00
ments are 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
builder will have the burden of proving that he did not build or int- BUILDING USE
prove for purpose ofsalc.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to e.minmt the project(Sec. 7044,Busies LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ABSESSORS PARCEL NO.
and Professions Code:l'he Conimctors License Law does not apply e
to an owner of properly who builds or improve thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts forsuch projeciswith a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Cantrn[tor's License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
auto
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby al firm that I 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,had,C.)
Policy Nc�Yl*Company r,unk- is'st
0 so Certified copy Is hereby furnished.
Z Z ❑ Certif copy is filed th h city inspection division. FIRE SPRINK ENERGY T24
O Applicant MISC.- REFER TO ORD. y❑ No Y ❑ N❑
CC w. PERMIT ISSUANCE 10.00
LU - C 'I'I FICATIi F I ATIO TION FROM WORKERS' FLOOD ZONE A.L.u.G.
W > COMPIiNSATION'INSURANCE PLG.CONTE. LIC.No. PLG.
CL O (Thu section need not he completed if the permit Is for one TOTAL Y❑ N❑ V ❑ N❑
Z) Z hundred dullms($100)or I..)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANIC �ER,'f 11T FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any mannerAL
so as toe
Ow become subject to the Workers'Compensation taws of Califomia.
Date-Applicant BUILDING
} y NOTICE TO APPLICNT: If,after making this Certificate of fix- ALTER OR ADD TO MECH. 1 _Q i 5.00
F Z emptlon,you should become subject to the Workeri Compcnsatiun APPLIANCE A 11� s� r 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 UNIT31T0 10,000 C. 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I p00C.EM.) 6.00 . SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.005-00
the performance of the work for which this permit is issued(Sec. O MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders amNe HEATING UI (OVER 100,000 B.T.U.)9.50
Lender's Nam HENNT E
ELECTRIC
. I certify that 1 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 PLUMBING
ordinances and stale laws relating to building construction, and BOILER-7(3H.P.or100,D00B.T.U.) 6.00
hereby autlmriu rupmwn[ativn of this city to enter upon the BOILER-COMP IOwr 100,000BTU)SEE FEE SCH. MECHANICAL 3
above-mentioned property for inspection purlNssLs.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any Way accrue,against said City in consequence of the PERMIT ISSUANCE 10.00 (j.W
got ling of ibis Permit, MECH,CONT. LIC.NO. MECH.
TOTAL ff�11 TOTAL
igmatum of App icanl Con[ r Date 31 t OV
OFFICE COPY