13195 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENTI FICATION PERMIT NUMBER
�mLotNc APPLICATION & PERMIT w �� ^�
f.wt,HESS ® !a 64a UILDING - ELECTRICAL-PLUMBING-MECHANICAL I l�
DWNER9 PLAN CHECK VALIDATION
/ "AME DTV. ELECTRIC PERMIT FEE
PNONE
1A.0 a �a �/ UTLETS-SWITCHES-RECEP 10.00/1.00
/ LIC.No. LIGHTING FIXTURES 10.00/1.00
TnACTons PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONa5;`L'VV PANELS 10.00 DATE OF APPLICATION
ORRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ADDDDRESS Enc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS
ADORE63 MOTORS SEE FEE SCH.
H 00 LICENSED CONTRACTORS DECLARATION SERVICE CHANGE 20.00
aG,v w I hereby affirm that I am licensed under provisions of Chapter 9 IS U NCE'dATE
(commencing with Section 7000)of Division 3 of the Business and
a ej, LOO. LE
ECT_' MECH.
H 0 x Professions Code, my he'..is in full fora f ct.
1 �y a ❑ ❑
i0 - LicenseLin Number
o N w-oDate--
Contractor '
~ J
a x ¢ a OWN[?R-BUILDER DE LARATION Viry"PI ING RMIT
A 0 A u `7 INFORMATION
w I. I hereby affum that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
H u Ores VALUATION S/FT.
g taw for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 %
Code:Any city orcounty whichrequlresolnc itto Lronstruct,alteq
t<¢ improve,demolish,or repair any structure,prior to ib issuance,also ELEC.CONTR. LIC.NO_ ELEC. /
0 LL requires the applicant for such Nomit to file a Signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
r Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe ,p
zo Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ 1 0 the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE90NSFFR,
a by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not mom than Five hundred dollars(S5000.):
❑ 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,win do the work,and the structure u not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's Licenu:law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-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.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or unprovemcnt 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. 3000 RES IND CON PB otn.
.
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Rosiness 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 projects
such pects with a contraetoq s)licensed pursuant to
the Contractor's h roLow. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for the WATER HEATER W/VENT 6.00
reason
Owner are WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconwnt to scl6inaure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3810,Lab.C.).
Pomy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y[:] N❑ Y ❑ NE]~ vs PERMIT ISSUANCE 10.00
LLJ CERTIFICATEOPSATION INS FROM WORKERS' FLOODZONE A.L.u.c.
L COA1 PIiN$ATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
C Z (Phis section need not be completed if the permit is for ane TOTAL
hundred dollars(S 1 OO)or less.)
U O I certify that in the performance of the work for which this per- MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is Issued,I shall not employ any peruses in any manner so as to
U W becomp�a-sy�jb��fa�cyT�l�q4}}lb Workers' fCalifarnia
OL DateJ!/Lj/�tL Applica BUILDING ��
} w. NOTI WIT after making this Certificate of I:x- ALTE -OR ADD TO MECH. 5.00 .f�
2 entption,you should become subject to the Workeri Compensation APPLIANCE 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 1Op00C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p0011F.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.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Neuse HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify 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 and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 6.00
L hereby authorize mpresentatives of this city to enter upon the BOILER-COMP (Over 1DO,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, Indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments,costs and expenses whichPERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of thio MECH.CONT. LIC.NO. MECH.
G' TOTAL TOTAL tS�dll
a are of Applicant/Contractor am `-
OFFICE COPY