12013 (2) I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 12013
nDDR 55
C, Unna A Place BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
. NAME _ GTY. ELECTRIC PERMIT FEE
Tohnson PHONE
CONTRACTORS
NAME Z OUTLETS-SWITCHES-RECEP 10.00/1.00
i�A ne �EY�TI LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACrOR's y APPLIANCES-RESIDENTIAL 4.00
ADDREaS 917
0
S ^SOS�r 41151
PHONE PANELS 10.00 DATE OF APPLICATION
OORRCHrtECT _ ' PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ADDRESS ENSPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP 'EMP.METER OR POLE INS. 20.00 7
APPLICANT'S MOTORS SEE FEE SCH. /f n.1✓.a_1
ADDRESS
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION Y
a iI hereby affirm that I am licensed under provisions of Chapter 9 �ZILISSUANCE DATE
(commencing will,Section 7000)Of Division 3 Of lh.Bm5ine55 and BLDG. ELECT. PLG. MECH.
H i Professions Code and my license H in full force and eff et ❑ ❑ ❑
z o m License Class Lic.Number
G r w Date 7 Contractor O.dA C
¢ a,2 -1 T BUILDING PERMIT
¢ ¢ w u OWNER-BUILDER DECLARATION INFORMATION
X o e N I hereby affirm[hal I am exempt from the Contractor's License MISC.- REFER TO OR
w 3 VALUATION $/FT.
H u o J Law for the following reason.(Sec.703 m Business and Professions
PERMIT ISSUANCE 10.00 '
w
w
Cade:Any city or county which requires a permit to construct,alter,
BE
¢ Q improve,demolish,or repair any structure. ELEC.CONTR. LIC.NO.ucture,prior to its issuance,also ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License /
HiQ
Law(Chapter 9(commencing with Section 7000)of Division 3 of thei�r`s"LdL
Business and Professions Cole)or that he is exempt therefrom and CITY PLUMBING PERMIT FEE -
Be the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant IDS civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).1:
O I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 oce.GROUP RES,UNITS
their sole compensation,will do the work,and'lhe 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 docs such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarc not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). RES IND CON PB Other
purpose❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ D C1 ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPARCEL NO.
and Professions Code:The Contractor's License Law does 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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam 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.
WORKF-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ml'consem to self-insure, - ZONING. ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division.
0 Applicant MISC.- REFER TO ORD. Y N Y ❑ N[]
vs PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU - CERTI FICCOI OF SATIOTINS FROM WORKERS'
W COMI'IiNSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (This section need not be completed if the permit is for one TOT v N Y ry
0 Z hundred dollars($100)or less.)
0 0 I certify that in the performance of the work for which this per- OTY MECHANICAL PERM T"~ FEE FEE SUMMARY
LL H mit is issued,1 shall not employ any person in any tanner so as to
U become subj cl{o the Workers'Compen Uo La�ves��,f.C�alifornia. V U
w Dal. Applicant Applicant !vim" f ALTER OR ADD TO MECH. I A' 15.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certi I,'ate of Ex.
F Z en,ption,you should become subject to the Workers'Compensation APPLIANCE5. Q (f PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be dm
eeed revoked. AIR HANDLING UNIT(TO 10,0 tP 4-.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1Q000 C.F.M.) 6.00 SEISMIC FEE
1 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 0"►
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 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-COMP 13 H.P.or 100,000 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. _i
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which _ CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting of this permit. /� MECH.CONT. LIC.NO. MECH. O.p
�\ �C Jay TOTAL
TOTAL
Signature ol'Applicanl/Contractor Date
OFFICE COPY