13244 (2) 1-c, �; •A ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
I O BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
6UILOING 13244
AOEysEss �s * BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
09 rafrwo 0 ds
OWNERS PLAN CHECK VALIDATION
NAME 7 QTY. ELECTRIC PERMIT FEE
6C/�7." PRONE
NOffNffE' Togs p Q t4, UTLETS-SWITCHES-RECEP 10.00/1.00
(-LT ,U'S
rt,6e LICNo. I 7 LIGHTING FIXTURES 10.00/1.00
ADDRESS APPLIANCES DRESS PPLIANCES-RESIDENTIAL 4.00
ADDRESS ''j
3 11J PHONE 321--5 PANELS 10.00 DATE OF APPLICATION
ORRCRI ECT . PANELS 200 AMP) 20.00 PLAN CHECK FEE .C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDREap ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
PLICA
NT APNT'S
ADDRESS MOTORS SEE FEE SCH. // J
C
SERVICE CHANGE 20.00
0 in
F o o LICENSIi D CONTRACTORS DECLARATION
<z W I hereby affirm That I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Professions Code, d y littnse is in full force yl e t ❑
H i f
Zoo Licensellaas Lic.Number r
H - Date Ly Contractor
r
P x 4 BUILDING PE MIT
¢ as OWNER-BU-DER DECLARATION
o a v, INFORMATION
w0¢ w 1 hereby offrm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
Fu0 < Law forthe following reason,(Sec,7031.5,Businessand ProfessionsPERMIT ISSUANCE 10.00 VALUATION
Code:Any city or county which requires a permit to construct,elteq
QQ ¢ 0 Improve,demolish,or repair any stmctum,prior to its beaR,,ee,also ELEC.CONTR. LIC.NO. ELEC.
wri¢ requires the applicant for such permit to file.Signed Statement that TOTAL PERMIT TO
9 he is licensed pursuant to the provisions of the Contractor's License G
Law(Chapter 9(commencingwith Section 7000)of Division 3 oflhe L
o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ g the basis for the alleged exemption.Any violation Of Section 703 LS STORIES TYPE CONSTR.
ce 3 - by any applicant for a permit subjects the applicant to a civil penalty
of not mom than five hundred della"(5500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 DCG 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 License Law don not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00
himself Or through his own em PIOYMS,Provided that such improve-
ments AREA are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 8.00 60
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM OVER 4 IEA) 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 Oth.r
❑ 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.D0 ASSESSORS PARCEL NO.
and Professions Cade: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 for such projects with a contractor(s)licensed pursuant to SEW ER-SANITARY-STORM EA.2008/10.00
the Contractors License Law.- U + TRACT NO, PARCEL N .
❑ I am exempt under Sec.-,BAP.C.for this
mason WA
TER HEATER W/VENT 6.00
Owner Date WATER SYSTEM" 5.00 - ACC.DATF 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 1 -� J _ ZONING ENG.SITE NO.
copy them gfs$ec�}eQl),Lub.C.). y 1 v ON(1eRtttsl
Policy No. mpeny r �I
0 ❑ CeRif¢d copy is hereby famished. CM) Is
'Z Z a✓Ce"ifie copy u f/ w'1fNyi thhe City in Fpection division. FIRE SPR INK ENERGY TYa
O Applicant LIOevl illit. I6/a.�r. Cu MISC.- - REFER TO ORD. v❑ N❑ v ❑ No
!rT) CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 O- FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
°' 0 (Thu section med not be completed if the permit u for one TOTAL / V❑ N❑ Y❑ N❑
::) Z hundred dollars($100)or less I
U O 1 certify that In the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
UL F- mit is issued,I shall not employ any person in any manner So as to
U become subject to the Workers'Compensation laws of California.
n Dale Applicant BUILDING
>_ W NOTICE TO APPLICANT:.If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F' ? emption,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 such provisions or this permit Shell be deemed revoked. AIR HANDLING UNIT(TO 1Q000QF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNMOVER 10=C.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. MICROFILM '
3097,CIv.C.). s HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
NH EATI NG UNIT(OVER ER 100,000 B.T.U.)9.50
Lender's Name ELECTRIC
I cenify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city end county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COTyP 13 H.P.or t00,0008.T.U.) 6.00
hereby authorize mpresenlatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP IOxer 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilitin,judgments, costs and expenses which CONST.TAX
[may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00mnli of Ihis permit , ..• MECH.CONT. LIC.NO. MECH.
�` TOTAL TOTAL
ignatum of Apphcwt Contmclor Date
OFFICE COPY