13236 (2) LOT- -ArIPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
7
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
Fq Y S C BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 13236
OWNER'S PLAN CHECK VALIDATION
NAME ,,��`` ''``VQTY. ELECTRIC PERMIT FEE
y, li PHONE
NOMERAcroRa UTLETS-SWITCHES-RECEP 10.00/1.00
(_3NI LLIC.NO
L 7 LIGHTING FIXTURES 10.00/1.00
.
r.ONrRAcroRs PPLIANCES-RESIDENTIAL 4.00
ADO_11R Ess (��
1l �r,&,J PHONE - PANELS 10.00 DATE OF APPLICATION
OgcwrecT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE .C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00
AESMOTORS SEE FEE SCH.
ADDRDDRESSS l�Zc1R/�/
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION -711/P7
a u b I hereby affirm that l am licensed under provisions of Chapter 9 ISSUANCE DATE
v, w (commencin with Section 7000)of Division 3 of the Business and
¢ g, g BLDG. ELECT. PLG. MECH.
P, e iz Professions Code, license s in full for
0 u Llcen
n c �L ❑ ❑
z o - u Class ss Number
oH o Date Contractor
H - J
¢ y f J BUILDING PERMIT
as OWNER-BUILDER DECLARATION
Ix w v INFORMATION
w ;LL r 1 hereby affirm that I em exempt from the Contractor's License MISE.- REFER TO ORD
.. 0 d Law for the following reason.(Sec.7031.5,Busineand Professions PERMIT ISSUANCE 1000 VALUATION 5/FT.
ss
� -w Code:Anycilyorcounty which requires a permit to Construct,alter,
¢ ¢¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
¢ requires the applicant for Such permit to file a signed statement that TOTAL PERMIT TO
A w he is licerued pursuant to the provisions of the Contractor's License - ^
r
Law(Chapter 9(commencing with Section 7000)of Di �vision 3 ofthe f'- 6
2 4 Business and Profession,Code)or that he isexempt therefrom and QTY. PLUMBING PERMIT FEE
S' H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the appplicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollen(S50 I.):
❑ 1,as owner of the property,or my sm ployces with wagesaz I BACK FLOW PROTECT. DEVICE 4.00 -� OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure a not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Lew does not apply to an owner of
property who bund,or improves themor,and who does such work FIXTURES-PER TRAP6.00 -- SEE FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
hmentsarenot intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4(EA) 200
builder will have the burden of proving that he did not build or in,- GAS . - . .
- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 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 E SORS PARCEL NO.
and Professions Code:The Contractor's Limnu 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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200@/10.00 A- TRACT NO. PARCEL NO.,
❑ 1 am exempt under Sce. ,B.&P.C.for this j WATER HEATER W/VENT 6.00 6
rcaaon
Owner Date ' WATER SYSTEMS 1 5.80 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP,vni 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure, Jv
or a certificate of Workers'Compensation Insurance,or a certified •res 1 ZONING ENG.SITE NO.
copy thereof c. 800,Lab.C.).
Polity No. Apany e„ L-
0 ❑ Certified copy is hereby famished. Q
Z = yjgQ Cer[ifl��yy..c py n wyyts��L �thIe ty IasipcCli yds ISIOn. •s• R FIRE BPRINK ENERGYT-24 '
FO Apolicant I� 1Ta�L5� YIUIY�sR6JZFF- L\ MISE.- REFER TO ORD. Y ❑ N❑ Y N❑
In
LU - CERTIFICATE
EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
IL COMPENSATION
PERMIT ISSUANCE 10.00 '-'-INSURANCE PLG.CONTE. LIC.NO. PLG.
1 Q section ❑ N❑ Y [:] N❑
(This ctldn need not be completed if the permit is for one TOTS V
Z hundred dollars(5100)or less.)
U O 1 certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner So as to ,
0w become subject to the Workers'Compensation laws of California.
ED Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} H NOTICE TO APPLICANT: IL after making this Certificate of Ex.
F ?
carnation,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 weh provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 110MC.F.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. HEATING NIT LTO 100,000 B.T.U.) 6.00 MICROFILM
3097,CN.C.). U
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.60
Lender's Address 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 BOILER-CONF(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-ciO to enter upon the BOILER-COMP (Or 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISE.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which
may in an way accrue PERMIT ISSUANCE 10.00 CONST.TAX
y y y against said City in consequence of the
granti Of this pe MECH.CONT. LIC.NO. - MECH.
airs �- � 07 TOTAL TOTAL
99atumof Applicant/Contractor DateI
OFFICE COPY