13410 (2) PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PR TIDENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
y A Es _ / ��y j/J DING—ELECTRICAL—PLUMBING —MECHANICAL 13410
W 'a /•V - PLAN CHECK VALIDATION
" D/�hOTVw. - ELECTRIC•PERMIT FEE
C TRACTaR's �n OUTLETS-SWITCHES-RECEP 10,00/1.00
rL(/ uc.ry -�[� LIGHTING FIXTURES 10.00/1.00
10 R R' APPLIANCES-RESIDENTIAL 4.00
A R
I �iION PANELS 10.00 DATE OF APPLICATION
ARCHITECT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
' uc.NO SIGNS TRANS. 3.00
ADDRESS ENG - SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP FrEMP.METER OR POLE INS. 20.00 A '
APP �"T MOTORS SEE FEE SCH.
AO SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION p -
ewi I hereby affirm that I am licensed under provisions of Chapter 9 ll gPJE B
r
G.2 a' (commencing with Section 7000)of Division 3 of the Business a
y ¢ _ BLDELECT PLG-- ECH.
H O i Professions C an y license is in full for
z O m — License Cla - Lic.Number
O z r O Dat Contractor
P m M..a .BUILDING PERMIT
M ¢ O E -BUILDER DECLARAT N
E 0 a O INFORMATION
R
g u y 1 herehy affirm that I ran exempt from the Contractor's License 'MISC.— REFER TO ORD
ra.O J Law for the following reason,(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION ,$/FT.
Code:Any city or county which requires permit to construct,alter,
rcuty ELEC.CONTR. LIC.NO.
¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.'
a O in requires the applicant for such permit to file a signed statement that TO,
`
,%a m LLhe is licensed pursuant to the provisions of the Contractor's License RMIT T
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the -
¢ Business and Professions Code)or that he is exempt therefrom and OTV: PLUMBING PERMIT FEE
K f p the basis for the alleged exemption.Any violation ru Section 7031.5 STORIES{-� �(TYPE CONSTR.
by any applicant forapermit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,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 (Set. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's 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 SG.FT.FLOOR AREA 'TOTALACREAGE
himself or through his own employees,provided that such improve-
Hunts are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 1 NC.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 im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30,00 RES IND CON PB Omar
,❑ 1,as owner of the property,am exclusively Contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL 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 contructoos)licensed pursuant to SEWER-SANITARYV-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
Date WATER SYSTEM 5.00
ACC.DATE ACG FILE NO.
OR(ER 1PENSATION DECLARATION WATER TREATING EQUIP. 5,00
1 hereby affirm that 1 have a Certificate of consent to self-insure;
ZONING ENG.SITE No.
or a certificate of Workers'Comp'
afon nsur n o ojy car Ifle
copy thereof(Sec.3800,Lah.C.).
Policy No. Company
O ❑ Certified copy is hereby fur he . FIRE SPRINK ENERGY T 24
' Z 2 ❑ Certified co n Iled w' he ci inspection divisi n.
MISC. REFER TO ORD.O Applicant Y ❑ N❑ Y ❑ NEIP: rnPERMIT ISSUANCE 10.00
K — CERTIFICATE OF EXEMPTION FROM WORKERS' FLOOD ZONE
LU COMPENSATION INSURANCE PLG.CONTH. LIC.NO. PLG.
CL Z (This section need not be completed if the permit Is for one TOTAL Y❑ N❑ V❑ N❑
hundred dollars($100)or IessJ e x
U OI certify that in the performance of the work for which this per- QTY'. MECHANICAL FEE FEE SUMMARY
LL 1— mit is issued,1 shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
It. Date Applicant• ALTER OR ADD TO MECH. 500 BUILDING
>_ GO NOTICE TO APPLICANT: If,after making this Certificate of Ex-
.
F E emption,you should become subject toThe Workers'Compensation APPLIANCE5,00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with r ~ FEE
V such provisions or this permit shall.be deemed revoked. AIR HANDLING LINA? �O 1 ,000C.F,M.)� 4.00 '
CONSTRUCTION LENDING AGENCY - AIR HANDLING UNIT(OVER,10,00DC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for DUCT) 5.00
the performance of the work for which(]its permit is issued(Sec. -- ICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,0Q91B.. .U.) 8.00
Lender's Name HEATING UNI ') dVER'10 '0 6B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING 2 �/�'
ordinances and state laws relating to building construction, and BOILER-CUMPI3H.P.Of 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 700,000 BTU)SEE FEE$GH. MECHANICAL
above-mentioned property for' ction purposes.
(We) agree to in mni and keep harmless the City of MISC.- REFER TO ORD.
Cupertino again I' iii s,j gments, costs and expenses which CONST.TAX
mayft..OEA,
eccr st said City ioisequence of the •PERMIT ISSUANCE _ 10.00
ME .CONT. LIC.NO, MECH..
OTA TOTAL
gplicant/Contmetar Date
OFFI COPY -