13269 (2) <�PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION
PERMIT NUMBER
BDILDIJe, APPLICATION & PERMIT
ADDm• .1, BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 13269
OWNER'S lT PLAN CHECK VALIDATION
NAME
� QTY. ELECTRIC PERMIT FEE
���
PHONE
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
It I c� LIC.ND� �� LIGHTING FIXTURES 10.00/1.00
woo ass TORSC�odllxu q APPLIANCES-RESIDENTIAL 4.00 ,
( 1HONE3 - PANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO SIGNS TRANS. 3.00
ARCHE OR ENG.
SPECIALCIRCUIT 5.00 PERMIT VALI DATION
zip -TEMP.METER OR POLE INS. 20.00
APPucANTsAOUDA FSS MOTORS SEE FEE SCH. ^
SERVICE CHANGE 20.00
C o LICENSED CONTRACTORS DECLARATION /C
Q U w I hereby affirm that I am Bcenxd under provisions of Chapter 9 q E KATE
w a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F N z Professions C e my license iso full fur a an eIT
Z o License Class Lic
- ❑ ❑ ❑
- .Num bar
D r Date �1_^�-�-1 Contractor
a >< BUILDING PERMIT
¢ a OWNER-BUILDI?R UE RATION
s o a INFORMATION
w ; LL R I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
F u o � Law for the following reason.(Sec 7031.5,Businessund ProfessionspERMIT ISSUANCE 1000 VALUATION $/FT.
Code:Any city or county which requires a permit toconstruct.almr,
rtrt Q o improve,demolish,or repair any structure,prior to its issuancE,also ELEO.CONTR. LIC.NO. ELEC.
O LL
ray vires the applicant for such permit to Ole a signed statement that TOTAL PERMIT TO
i
w $ re is reamed pursuant to the provisions of the Contractor's License
w a a 4aw(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i o Business and Professions Code)or that he is exempt therefrom end QTY. PLUMBING PERMIT FEE
¢ w $ the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TYPE CONSTR.
A , by any uppGcant for a perms(subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than Five hundred dollars($500).1:
O 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7000, Business and Professions DRAIN$-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
• property who builds or improvo thereon,and who docs such work F IXTUR E$-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.ll',however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement is suld 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. RES . IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with 00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.DO ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to mi owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractogs)licensed punuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec. ,tl.&Y.C.for mis WATER HEATER W/VENT 6.00
reason
Owner Dare WATER SYSTEM 5.00 ACC.DATE ACL.FILE NO.
WORKERS'COMPENSAT10N DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZOrvING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
ropy them,n](Sec.3600,
00.Lab.C.). n �AI /�
POP N Company PR fs N
Q "'Certit7 opY is hereby furnished -
z Z ❑ Certip� copy is fled th�l�aity inlpectiol division.
FIRE SPRINK ENERGYT2d
0 Applicant- � /y"Q-•✓�*+�J MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ rv❑
~ w+. PERMIT ISSUANCE 10.00
ft. - RTIFICCOI PC EXEMPTION INSU OM WORKERS' FLOOD ZONE A.L.U.C.
W � COMPENSATION INSURANCE PLG.COrvTR. LIC.NO. PLG.
CL O (Phis section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
D Z hundred dollars 1$100)or less.) i
U O 1 certify that in the performance of(he work for which this per. QTY. MECHANICAL PERMIT,' FEE FEE SUMMARY
LL F our is issued,I shall not employ any person in any manner:,as to
O 0 become subject to the Workers'Compensation Laws of California.
Date ApplicantALTER OR ADD TO MECH.L �'035.00 BUILDING
>_ y NOl'ICE 'f0 APPLICANT: If,after making this Certificate of fix _p
F-. ? emption,you should become subject to the Workers'Compensation APPLIANCE ,J l d 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 UNIT(TO 1001 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 S- O
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00 �.OV
Lender's Nam
ddHEATING UNIT(OVER 100,000 B.T.U.)Lenders Address
Addrr ess ELECTRIC
1 certify that I have mad this application and state that the above VENTILATION FAN (SINGLE) 4.00 OV
information u comet. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize roperty for ins ec this city es enter upon theatoveBOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL 3 /
hereby
aut orizned property forinspOrth i purposes.
(We) agree to save, indemnify and keep harmlm ilia City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 0 q0 CONST.TAX
may in any way accrue against said City in consequence of the L
gra ng of this pemiL MECH.CONT. LIC.NO. MECH.
• --1-?7 TOTAL w TOTAL
gnature at Appheart Conl r Date 7 1.Vo
OFFICE COPY