13510 (2) 40PLICAN TATO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION J PERMIT NUMBER
BUILDING APPLICATION & PERMIT 13510
ADDRESS BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
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Cavae.Is VPLAN CHECK VALIDATION
Jda A /'� NAME /D/ OTY. ELECTRIC PERMIT FEE
PHONE
CNAME
ONT Ac p s UTLETS-SWITCHES-RECEP 10.00/1.00
TLe--m Ig LIC,NOE27e4 QG LIGHTING FIXTURES 10.00/1.00
ADDRESS tun's PPLIANCES-RESIDENTIAL 4.00
PHONE - PANELS 10.00 DATE OF APPLICATION
CHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
on
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ADDRESS ENC. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS ESS
AMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 CpLCJ
o ¢i
F 02 LICENSED CONTRACTORS DECLARATION
a U v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
G
2:"" (commencing with Section 7000)of Division 3 of the Business and¢ n BLDG. ELECT. PLC. MECH.
H 7 i Professions Code. d l}i ease is in full fo1W: e t
Z 0�_ License Class- _ G Lic.Number �L /O!�kEl El El
4 w Dalc Contractor
a ms BUILDING PERMIT
Or ¢o u U OWNF.R.BUILDER DECLARATION INFORMATION
w ; a_n I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
LL o a Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/PT.
� - v, Code:Any city orcounty which requiresa permit toconstruet,alter,
or ea improve, or repair any structure,prior to itsissuance,also ELEC.CONTR. LIC.NO. ELEC.
0 LL requires the applicant for such permit m file a signed statement that TOTAL PERMIT TO
K
$ he is licensed pursuant to the provisions of the Contractor's License . ,r .t�.1✓T/
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and
sir
¢ H m
the basis for the alleged exemption.Any violation of Section]031.5 QTY. PLUMBING PERMIT FEE
STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant o a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their Sole compensation,will do the work,and the structure is not DCO.GROUP RES.UNITS
int Dried or offered I'or sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 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 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenetintendedoroffered 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 BUILDING USE
builder will have the burden of proving Ono he did not build or im-
proveforpurposeofsaleJ. 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,BasincuLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contramods)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT N0, PARCEL NO.
❑ Iamexemptunder Sec. ,B.&P.C.tor this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent m self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compchm ion Insurance,or a certified
copy thereof(Sec.3800,Lub.0 I
Policy No. Company L
O _/ O Certified Copy is hereby furnlaled. FIRE SPRINK ENERGY T-24
Z Z/' )p Certified cgyyAisfileyl.jvi the city inspumion division. MISC.- REFER TO ORD. 0 ❑
�O Applicant ��/l Q� V N V N
cc: y CERTIFICAT'I:OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.O.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v N v N
0- 0( This section need not be rompleted if the permit is for one TOTAL El
hundred dollars IS 100)or Ic..)
U O 1 certify that in the performance of the work for which this per- GTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not enploy any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
Dutc Ar licum i BUILDING
W 1 p ALTER QR AD Ti0 MECH. 5.00 d�
} m NOTICE TO APPLICANT: If,after making this Certificate of E.-
f.. ? emption,you should become subject to the Workers'Compensation APPLIANCE q J"• 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 log M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLIN -UMT(OV 1 GEM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOO •(W P UCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT ffO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I have reed this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMPO H.P.or 100,000 B.T.U.) 6.00
hereby entioned representatives forms inspection
this city es enter upon the BOILER-COMP (Over 100,000 STU)SEE FEE SCH. MECHANICAL XS
7�
above-mentioned property forinspof this
purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which ,f W CONST.TAX
may in any way accrue against mid City in consequence of the
grantiPERMIT ISSUANCE 10.00d
ng this pe in MECH.CONT. LIC.NO. MECH.
r'//�/�����7 TOTAL TOTAL
Signa reof Appllcam ontractor Date
OFFICE COPY