13350 (4) _ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
.'BVILJI/ PERMIT NUMBER
PROJECT IDENTI FICATION APPLICATION & PERMIT
aGl`Gm° 13350
AO RFss
l�C� Y`✓ ILDING - ELECTRICAL-PLUMBING-MECHANICAL
NWMER S L Il PLAN CHECK VALIDATION
Y- :! QTY. ELECTRIC PERMIT FEE ^
PHON /Y 6 � VLH_+-11�J_
coNTRACTDRs OUTLETS-SWITCHES-RECEP 10.0( .00 _
AME
/� uc.No. LIGHTING FIXTURES 10.00/1.00 �`5
CONTRACTORS APPLIANCES-RESIDENTIAL 4,00
aooxRj C 1,
W ',{„5/-{ d, F PHONE�stp 3315 PANELS 10,00
DATE OF APPLICATION
ARC
NIT[CTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER _
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR RESSENG SPECIAL CIRCUIT 5,06 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
AUDRESSS MOTORS SEE FEE SCH. F
SERVICECHANGE 20.00
w o o LICENSED CON'I'RACI'ORS DECLARATION L�(1/0 a
¢ -u 1 hereby affirm that I am licensed under provisions of Chapter 9 l fG ATE
a
y Q - (commencing avid,Section 7000)of Division 3 of the Business and BLDG. ELECT. 'PLG. MECH.
r D Z Professions Code nd my license is in full f.,cc d'lc. ❑ ❑ ❑ ❑
Z 0,.vj- License las Lic.Numb _/V
o Z F Data
Contracmr JlJ6IL7 L1.-
a y f BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION INFORMATION
0nU MISC.- REFER TO ORD
X ;w y I hereby affirm that I am exempt from ilia Contractor's License VALUATION a. O4 Law for the following reason.(Sec.7031.5,Businessand Professions pERMIT ISSUANCE 10.00 SIFT.
Hy Code:Any city orcounly which requires a permit to ter,
Q
ceQ Q 2O Improve,demolish,Or repair any Machine,prior to Its issuance,also ELEC.CONTE. LIC.NO. ELEC.
-DLL requires the applicant for such permit to file a signed statement[hal TOTAL PERMIT TO
e w m he is licensed pursuant to the provisions of the Contractor's License /N��/�
FZi Law.(Chapter 9(commencing with Section 7000)of Division 3 oflhe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
ce 1- $ the basis for the alleged exemption.Any violation of Section 7031.5 - STORIES TYPE CONSTR.
n by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATEfl (EA.) 5.00
'
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages asBACKFLOW PROTECT.DEV ICE 4.00 OCC.GROUP REB.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 S'
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 S¢FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM•11NC.40UTLETS 6.00
ments are not intended or offered for sale.If,however,the building '
or improvement is sold within one year of completion,the owner
.
.
.-GAS EASYSTEM-OVER 4 IEA) 200
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 PS Gum,
❑ I,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 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 contmcdorls)licensed pursuant to SEWER-SANITAR V-STORM EA.200tt/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM - 5.00
ACC.GATE ACC FILE N0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ' ENG.SITE N0.
or a certificate of Workers'Comp
Compeppca tion Insurance,or a certified
Copy thereof(See.3800,Lab.CJ1L?4 6A-)A tt. ?- +
Policy No. Company //���//��//
O Certified copy is hereby furnished FIRE SPRINK ENERGY T.24
Z Ce c py Is Ole wit the city inspectyon division. MISC.- REFER TO ORD.
py ApPlicunt Y ❑ N❑ Y ❑ N❑
Cc CERTIFICATE OF L PTION FROM WORKERS' PERMIT ISSUANCE 10.00 /6 FLOOD ZONE A.L.U.C.
Ud COMPENSATION INSURANCE PLG,CONTE. LIC.NO. PLO
CL O /5, ❑ ❑ E] NEI
section need not be Completed if lire permTOTAL
it is for one Y N Y
=) Z hundred dollars[$100)or less.)
L) O I certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL E. 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
o,
Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING '7 Z0
>- W NOTICE TO APPLICANT: If,after making this Certificate of Ex.
H Z emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 14000GFM.) 6.00 SEISMIC FEE 3
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097 eCiv.C.jnce of the work I'or which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Nam Al
Lender's Add,ss - HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify chit I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00 _
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and stale lows relating to buildingconstruction, and BOILER-cUMP I3 H.P.or 100,000 B.T.UI 6.06
herby authorize representatives of this city do enter upon the BAILER-COMP IOver 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned properly 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
may in any way accrue against said City in consequence of the
g this ermit. • MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sig lure of Applicant/Contractor Date
OFFICE COPY
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