13340 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING
ADDRESS APPLICATION & PERMIT . O
A
O -7 �AQq��£ SZ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
7 OwNEH'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
1 1 PHONE2S-7'L
coN�T`RAcroRs77N UTLETS-SWITCHES-RECEP_ 10.00/1.00
NAH / ` n, LIC.No.04472- LIGHTING FIXTURES 10.00/1.00
CONTR
4DDRESLTOR's "1 APPLIANCES-RESIDENTIAL 4.00
O / / PHONE ?_7e"
n O(LL PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLI CSNr's
ADDRESS MOTORS SEE FEE SCH.
,fJ
SERVICE CHANGE 20.00 /�•��'L(/"'LGL_•
w 0 0 LICENSED CONI'RACfORS DECLARATION
a u v 1 hereby IT...that 1 em licensed under provisions of Chapter 9 ISSUANCE D E
h G w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r D z Professions Cod em my license is in full force c fVt0 .�7 ❑ ❑ ❑
z O,% Li<cnse, Lic.Number_
o r w De1c Cuntmctor
er y 21 BUILDING PERMIT
Ce s4i OWNER-B UILDER DECLARATION INFORMATION
w ;LL N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION
F .. 0 a taw for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires permit tocomtnct,.1ol,
re 2 a a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ar, O LL requims the applicant for such permit to file a sighed statement that TOTAL PERMIT O
w 9 he is licensed pursuant to the provisions of the Contractors License
H z r
Law(Chapter 9Commencingwith Section 7000)of Division 3 ofthe /�/
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE vl�
ce I$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the 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 Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 S.O.IT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenot intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
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 NI- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contrrs actoto construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 A ESSORSPARCEL NO.
and Professions Code:The Contractor's License taw don 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 contmemAs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License taw. TRACT No. PARCEL NO.
C, I am 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 NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Se 11 I,CG).
Policy No.Q=� pany 'A1ht5T1ehI /4/K"O-
O ❑ Certified copy is hereby furn ed. FIRE SPRINK ENERGY T-24
Z Z � Certified, s f'•d t the city in yyti�II �}�sslon.
Applicant -(2�N�- MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
I- w PERMIT ISSUANCE 10.00
jr - CERTIFICATE E SATIO ION FROM WORKERS' FLOOD ZONE A.L.u.c.
W �_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL ❑. 1This section need not be completed if (lie permit is for one TOTAL Y❑ N❑ Y ❑F N❑
� Z hundred dollars IS 100)or less.)
L) O 1 certify that in the performance of the work for which this per- CITYMECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of Califomia.
soDatc Applicant ALTER OR ADD TO MECH. 5.00 - BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F2 emplion,you should become subject to the Workcm'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Libor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER C.F. ) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WI CTI 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). ' HEATING UNIT(TO 100-DOR ii . '.) Q.^"
Lender's Name HEATING UNIT 0B.T .50 _
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (S LEI 4.00
information Is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COfvP(3 H.P.Or 1004&0 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH: MECHANICAL
above-mentioned property for inspection purposes. 0-0
(We) agree to save, indemnify unit keep hamdess the City of MISC.- REFER TO OR[t.
Cupertino against liabilities,jud 'tents,costs and expenses which fj ny CONST.TAX
may
m 'q.•aR ay ecru p�I said Clty in consequence of the PERMIT ISSUANCE 10.00
gnting' f p MECH.CONT. LIC. O MECH.
L s. A /l N 3°¢��z TOT�L� oa TOTAL
Signsl rt dA elicant/Comrac r Uete
OFFICE COPY