13271 (2) _--/SPPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOI NG PROJECT I DENTI FI CATION PERMIT NUMBER
ADORE APPLICATION & PERMIT
ADORE 13271
ss p
M I� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
O'NNER'S PLAN CHECK VALIDATION
NAME _ QTY. ELECTRIC PERMIT FEE
�r PH.N
CIONTERACTOR's UTLETS-SWITCHES-RECEP 10.00/1.00
ITLJ� _L� 4�F sec.No�� '-( LIGHTING FIXTURES 10.00/1.00
A 7RAc7oR's r _02, APPLIANCES-RESIDENTIAL 4.00
O ,y,t,L PHONE 71 - ,CX30 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE .C.NO.
Off
o
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENO. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
"DDRES s Nr'3 MOTORS SEE FEE SCH.
Pat Es
SERVICE CHANGE 20.00 / f
woo LICENSED CONTRACTORS DECLARATION ( 4F 17
< u u 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.
F D z Profsions Coda, my license is in full fore c fect. ❑ ❑ ❑
o z n W License ss C.a7 Lic.Number
Ua1e � -Contractor
a Y f BUILDING PERMIT
a a c OWNER-BUILDER DE RATION INFORMATION O MISC.- REFER TO ORD
K
ta H I hereby collo that I so exempt from the Contractor's License VALUATION S/FT.
r- .. w lawforthefollowingreason.(Sec. uires a,Bmit toasu Professions PERMIT ISSUANCE 10.00
acu Cade:Any molish county which reqstructure,prmittoromuancalter, ELEC.GONER. LIC.NO.
I[ , ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.
T TO
se
K O M requires the applicant for such permit to file a signed statement that TOTAL
K
$ an
he is licensed pursuant to the provisions of the Contractor's License PERMIT
TO
I_ 2 > bow(Chapter 9(commencing with Section 7000)of Division 3 ofthe A4 (-ff-
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
CE the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i g by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(5500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
O I,as owner of the property,or my employees with wages as BACK F LOW 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(See. 7044, Business and professions DRAINS-FLOOR,ROOF,AREA,COND- 5.00
Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who don such work FIXTURES-PER TRAP 5.00 . SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments am not intended or offered for mk.If,however,the budding GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM OVER 4 (EA) 200 BUILDING USE
builder will have the burden of proving that he did not build or im- - . . RES IND CON PB Om-
INDUSTRIAL for purpose ofmle.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licnaed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and professions Cod,The Contractor's License Law does not apply t f
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 1p
contracts for such projects with a eontramons)licensed pursuant t. SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO, PARCEL NO.
❑ lure exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm (bat 1 have a certificate of consent In self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensalion Insurance,or a Certified
copy the r�yf(Sec 3800.Lib.C.l. p
Polic'NrK(,54 `�1rCompany `�1.(1a� 1NS .
O �CCrtlfled ' py is hereby furnished. FIRE SPRINK ENERGY T,,-Z4
z Z ❑ Cenifc opy d film wyh the ny inspection division.
p Applicant «� MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
CCT C: TIFICATE OF EXEMPTION PROM WOR PERMIT ISSUANCE 10.00 FLOODZDNE A.L.u.C.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. p PLG.
fl O 1'I his,section need not be completed if the permit is for one /Y�D TOTAL Y❑ N❑ Y ❑ N❑
Z) Z hundred dollars(5100).,leas,)
U O I certify that in the perfomtonw of the work for which this per- CITY MECHANICAL PERMITNj J) FEE FEE SUMMARY
LL 1- mil is issued,I shall not employ any person in any roamerso as to S1•s1
Q Q become subject to the Workers'Compensation Laws of California.
UJIOL. an
Dale Applict BUILDING
>_ W NOTICE.TO APPLICANT: If,eller making this Certificate of Ex- ALTER OR ADD TO MECH. �6ID0
F ? emptlon,you should become subject to the Workeri Compensation APPLIANCEOl T 5.00 PLAN CHECK
provisions of the labor Code, you must forthwith comply with FEE
U such provisions.,this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby art= that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 (jLD
the perfor ana of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's No HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 06
Information is Leman.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.Rat-100,0DOB.T.U.) 6.00
hereby authorize representatives of this city to enter upon the g01 LERCOMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL ¢
above-mentioned property for inspection purposes.
(We) agree to met, indemnify and keep harmles the City of MISC.- REFER TO ORD.
Cupertino against Gabilili s,judgments, costs and expenses which PERMIT ISSUANCE 10.00 Q,(� CONST.TAX
L'm
may in any way ace against said City in consequence of the
gra go f this permit - MECH.CONT. LICNO. MECH,
7_ TOTAtL� TOTAL
Ignetumof Applicant/Contras r Dale
OFFICE COPY