13275 (2) _ rAPPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CTlDENTIFICATION
PERMIT NUMBER
BUILDING PROJE
BUILDINGAPPLICATION & PERMIT
ADDREss
a \ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
13275
OWNER'$ --ll.• PLAN CHECK VALIDATION
"AMECITY. ELECTRIC PERMIT FEE
1TRACrc1 Cons• DH -?moi
NOMEAcrDRs UTLETS-SWITCHES-RECEP 10.00/1.00
LIC si-Z,111 L46-7 ILIGHTING FIXTURES 10.00/1.00
ADDRESS
�s�. APPLIANCES- 4.00
CONTRACTORS
1Vyrm
vHONE 3']"j- PANELS IO.00 DATE OF APPLICATION
AORCRITECi PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,No, SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG. . SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 n
ADDRESS rs MOTORS SEE FEE SCH.
APPLICA
SERVICE CHANGE 20.00
ac
Foo LICENSED CONTRACTORS DECLARATION
u w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m < BLDG. ELECT. PLG. MECH
(commencing with Section 7000)of Division 3 of the Business and .
H o z Professions Code,an my license is in full ft,yc and effect ❑ ❑ ❑
z o 'v� - License CI v Lic.Numbe
H w Date Contractor
a m s BUILDING PERMIT
¢ a OWNER-BUILDER DE RATION
¢o a o - INFORMATION
X ; LL h I hereby offirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
H ¢ o j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
Code:Any city or county which requiresa permit to cc nstrua,alteq
QQ¢ Fo improve,demolish,or repair any stmctum,prior to its ix uance,also ELEC.CONTR. LIC.N0. ELEC.
w0¢requires the applicant for such permit to file a signed statement that TOTAL PERMIT T
2 he is licensed jo ant to the provisions of the Contractor's License M
H z i 4aw(Chapter 9(commencing with Secion 7000)of Division 3 ofihe
¢ o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢F$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIESTYPE CONSTR.
i ; by any applicant for a permit subjects the applicant loo civil Penalty
of not mom than five hundred dollar;(S500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the properly,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will du the work,and the structure is not
intended or offered for sale (Sec. 7044. Business and Profmions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License taw does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 so.FT.F LOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of saluJ. INDUSTRIAL WASTE INTER. 3000 RES INO CON PB Omer
❑ I,as owner of the proper .
Y•am exclusively contracting with El EJ ❑ ❑ ❑
licensed cmuntetore to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL No.
and Professions Code:The Contractor's License Law docs 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 contractions)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under See.-,B.&P.C.for this WATER HEATER W/VENT 6.00 -
Mason
Owner Date WATER SYSTEM 5.00 ACGDATE ACC.FILE NO.
WORK E RS'COM PENSATION DECLARAI'ION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a cenif wale of consent to.1hinsum.
or a certificate of Workers'Compensation Insurance,or u certified ZONING ENG.SITE NO.
copy the,g,-f_(s_ec.3g00,Lah.C.).� rB
I dry
Policy No/ 3)•_(j}I Company l�y..�_P`Jo' l
Q ❑.Cenfre copy is hereby furnisheA. FIRE SPRINK ENERGY T-24
Z Z 9 Cent f copy is II h he cit 'ispection division.
O Applicant MISC- REFER TO OR D. Y0 N� v � No
m y2 :RI'1171CA'1'1:017 EXEMPT] WORKERS' PERMIT ISSUANCE - 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (This section CH not he completad if the panni) b for one TOTAL Y N� Y [] No
Z hundred dollars IS I W)or hM,)
U O 1 cenify that in the performance of the work for which this per- CITU. MECHANICAL PERMIT P� FEE FEE SUMMARY
LL I- mit is issued, I shall nut employ any person in any manner so as to V
U become subject to the WorkcO'Compensation Laws of California. .• T1 ^ i,4
0. DateApplicantALTEfl OR ADD TO�MECH` .00 BUILDING
} W NOTICE TO APPLICANT': If,atter making-this Certificate of Ex.
F.. Z
sorption,you should become subject to the Workers'Compensation APPLIANCE { P. ss 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( 'O 1oj100C.F.M.) 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10p00 C.EM.I 6.00 SEISMIC FEE
I hereby affirm that there is a construction]coding agency for EXHAUST HOOD (WITH DUCT) 5.00 (�,]
the performance of the work for which this permil is issued fSec. MICROFILM'
3097,Civ-C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 ,p
Lender's Name
Address
LendHEATING UNIT(OVER 100,000 B.T.U.)9.50
er's Address ELECTRIC
toI certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is Street. I agree to comply with all city and county PLUMBING
hereby
ncu and state laws relating to building construction, and BOILER-OOfa1P(3 H.P.or 100,0008.T.U.) 6.00
aconey authorize roperty for ins ec This city to enter upon the BOILER-COMP t0ov,100,000 BTU)SEE FEE SCH. MECHANICAL
bove-mcntioricd properly for inspection purpoxs.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs orad expenses which PERMIT ISSUANCE 1000 CONST.TAX
Cupertino
in any way acme.against said City in consequence of the 1 0-U
g ing of this permit. MECH.CONT. LIC.NO. MECH.
Z 7 �/1 TOTAL TOTAL
IVatum of ApplicantlContr1clor Dat
OFFICE COPY