13540 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
-_4 " BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BOILDING APPLICATION & PERMIT
A°°REaB 13540
to/_4 r-. yV�Er�rl �rylhn BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
XOINNER'S Y/O PLAN CHECK VALIDATION
E PITON 4r�I Z QTY. ELECTRIC PERMIT FEE
co /cT Rs
NAME 773-/9F/19 OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1,00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE 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
ARCH.OR ENG. 5.00 PERMIT VALIDATION
AooREss SPECIAL CIRCUIT i-.A
nv
EMP.METER OR POLE INS. 20.00 "
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE20.00
�r rurrti
w o o LICENSED CONTRACTORS DECLARATION - _ �f Q�! /L�p3 5
a u I hereby affirm that I am licensed under provisions of Chapter 9 �, - _ �'• ISSUANCE DATE
H <w (commencing with Section 7000)of Division 3 Of the Business and a5.00
LDG. ELECT. PLG. MECH.
H N 0 Prolbssions Code,and my license is in full force and effect. k ❑
z o u - License Class Lia Number lain/ C� �I!Q y Date Contmcmr(E Ic w ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
REFEINFORMATION
ww I hereby affirm that I am exempt from the Contractor's License MISC.— VALUATION $/FT.
o aLaw for the following reason.(Sec.7031.5.Businessand Professions pERM1T ISSUANCE J/Code:Any cityorcounty which requires a permit to Construct,alter, _7/lbrt ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.C. requires the applicant for such permit to file a signed statement that PERMA.
w8 he is licensed pursuant to the provisions of the Contractor's License qaLaw(Chapter 9(commencing with Section 7000)o fDivision 3 of theJ•f/f/{Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMITE is
the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TY E CONSTR.
i ; _ by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN&VENT-WATER /Q[nytmoretan five hundred dollars(5500).):XIsowner of the property,or my employeeswith wagesas BACK FLOW PROTECT. DEVICEthel sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,C . .
Code.The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work 3 F IXTUR ES-PER TRAP 5.00 Q SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsare not intended°,offered for sale.If,however,the building GAS-EA.SVSTEM-1 6,00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or am- RES IND CON PB Omer
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC'5 V.B.) 6.00 ASSESSOR5 PARCEL NO.
and Professions Code:The Contractors License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERSA OVER 5(EA.) 1.00
contracts forsuch projects witha contractods)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractors License Law.
❑ lam exempt under Sec.—,BAP.C.for this WATER HEATER W/VENT 6.00
reason ••'
Owner - ) Dale�p/�// WATER SYSTEM Sglf Q( UllwaP• 5.00 ACC.OATE ACC.FILE NO.
Id KERS'COMPENSAT'ION 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 th erect(Sec.3800,La b.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T@4
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. Y ❑ N❑ v [3 No
Applicunt
CCN CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
lU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. YE] N❑ v ❑ N❑
CL O (This section need not be completed if the permit is for one TOTAL
::) Z hundred dollar,0100)or less) r
U 0 1 certify that in the performance of lite work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
, H mit is issued,1 shall not employ any perwo in any manner so as to
O w becomes bjc t to the Workers m a{ n Law of California. {/, /�
Date Applicant ALTER OR ADD TO MECH. 5.00—
.00 BUILDING 50 6V
} y ND7'I PLICANT: la ung this Cc o Ex-
F ? emptioo,you should become sat to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.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 Name HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC �-
Lender's Address
1 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-COMPI3 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.
(We) agree to save, indemnify and keep harmless the City of Misc.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
A
may in any way accrue against said City in consequence of the
gontingord ,mit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signal ppImant/Contract r ale
OFFICE COPY