13273 (2) !APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
ADILDING APPLICATION & PERMIT
OOREss 13273
ao FA1r BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAMEQTY. ELECTRIC PERMIT FEE
UlrRS PHONE
-
NnMERacroRs UTLETS-SWITCHES-RECEP 10.00/1.00
uc.No.31-ly LIGHTING FIXTURES 10.00/1.00
CONTRACTOJ::{a PPLIANCES-RESIDENTIAL 4.00
ADDRESS ��L� -T�-a ��� _
\ PHONE 3 / ( ZCW PANELS 10.00 DATE OF APPLICATION
OORRCHOEcr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE .NO.
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ARCH.ia eNO. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 �(
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
m o o LICENSED CONTRACTORS DECLARATION
4 v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H G w (commencing with Section 7000)of Uvlsio0 3 of[he Business end BLDG. ELECT. PLG. MECH.
F n w Professions Code,and my license is in full f me and IT 1. ❑ ❑ ❑
z o u, - License Class CO Num
E m Date .� s? Contractor
y BUILDING PERMIT
¢ ¢ w o OWNER-BUILDER DE I ARATION INFORMATION
w ;LL y law for the following reason.(Sec.7031.5,BusinessenJ Professions 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION S/FT.
ac PERMIT ISSUANCE 10.00
EPI 0 Z Code:Any city or county'which requires a permit to Construct,alter, ELEC.CONTR. LIG NO.
re ¢ ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC. .
rs u requires the applicant for such permit 10 file a signed statement that TOTAL PERMIT T
K
$ he is licensed pursuant to the provisions of the Contractors License
ca
H z a Law(Chapter 9(commencingwith Section 7000)of Division 3 oflhe
Business and Professioro Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢F the basis for the alleged exemption.Any violation of Sectio,7031.5 STORIES TYPE CONSTR.
d ; by any applicant for a permit subjects the applicant tog civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of lire 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,AREA,COND. 5.00
Code:The Contractor's Limsse law dols not apply to an owner of
e propeNy 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-
memsucnotintendedoroffendforsak.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
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 im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
0 I,as owner of The properly,am exclusively contracting with ❑ ❑ El 1:1licensed contractors In construct the project IS". 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code: rhe Contractor's License Law docs not apply U'
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 mntraclogs)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contmvlru s License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-.R&P.C.for this WATER HEATER WIVENT 6.00
reason
Owner Dam WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofeonsenl to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3SOO,Lab.C.).
Policy No Company- d i A I 1n
U G Frifi�I cop is hereby furnish J.
Ccrllf ' `o is fi1s�4� I cit inspection division. FIRE SPRINK ENERGY T�Y4
Z p ppplica,t `� ierr�ry,..,.Yw� MISC.- REFER TO ORD. v ❑ N❑ Y ❑ N❑
~ H. PERMIT ISSUANCE 10.00
� - ,:RTIIPICATI:OF EXEMPTION FROM WORKERS' FLODDZONE A.L.UG.
LU 5; COMPI!NSA'I'ION INSURANC17 PLG.CONTR. LIC.NO, PLG. Y❑ N❑ V❑ N❑
CL Z (T 'his section deed not 1H, completed if the permit is for one TOTAL
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of(lie work for which this Ivor- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued, 1 shall not employ any person in any manner m as to
become subject to the Workers'Compensation Laws of California.
0 C. Date Applicant ALTER OR ADD TO ME Fi.�+11�' 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of nix- _
? emption,you should become subject to the Workers'Compensation APPLIANCE .15.00 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,10,000C'F.M.P 14.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that them is a construction lending agency for EXHAUST HOOD(WITMJDUC iPPUIt1ll .00 5rU
the Performance of the work for which this permit A issued(Sec. MICROFILM
3097,C1v.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00 g,0
Lender's Name H EATING UN IT(OVER 100,000 B.T.U.)9.50
Lender's Address I ELECTRIC
• I certify that I have read this application and slate that the above 2„ VENTILATION FAN (SINGLE) 4.00 .(3 C)
inforination is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws refiling to building construction, and BOILER-CDi H.P.or 100,000 B.T.U.) 6.00
hereby euthori, representatives of this city to enter upon the BOILER-COMP Inver 100,0130 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(Wt) agree to save, indemnify and keep harealesa the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which' PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue-against said City in consequence of the 10,C)0
gra ing of this permit. TOTA
MECH.CONT. LIC.NO. MECH
In .
L
1 TL
ignalureofApplitant/Con[ or Dale s0` OTA
OFFICE COPY