13147 (2) (-APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY o8 3
pD,L ENG
U APPLICATION & PERMIT
ILDING PROJECT IDENTIFICATION PERMIT N MBER
�y
GLL�1, Q C ryl BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 13147
o N RIL
'S ✓LC-Iv PLAN CHECK VALIDATION
L.
A./Y! /n/J/ o� OTY. ELECTRIC PERMIT FEE
CONTRACTOR'S ✓ 2O UTLETS-SWITCHES-RECEP 10,00/1.00
;6(v &A Q [�
d LIC,N0,27gM LIGHTING FIXTURES 10.00/1.00
CONTRAc R's APPLIANCES-RESIDENTIAL 4.00 -
A 0a OX 1196 PHONE _ / / PANELS 10.00 DATE OF APPLICATION
ARCHITECT (JP q-Ogl4.- PANELS (OVER 200 AMP) 20,06 PLAN CHECK FEE
OR /� UI f
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ADDRRESSs ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS rs MOTORS SEE FEE SCH. "�
ADDRESS -urQN��
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION l0
¢u U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m z "' (commencing with Section 7000)of Division 3 of the Business and
¢ H / BLDG. ELECT. PLG. MECH
w Z Professions Code nd icenre is in full foree� q
z O y - Littnse C ass. �� Lic.NumberJ�Lq v
o m w Date Contoutor _Ll_
st se F V BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILD17R DECLARATION
o a MISC.- REFER TO ORD INFORMATION
w 3 w 1 hereby affirm that I aha exempt from the Contractors License VALUATION
F a_ O¢ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or cour ry which requires a permit to construct,alter.
Qso Q 7 Improve,demolish,Or repair any structure,prior to Its Issuance,also ELEC.CONTH. LIC.NO.rE ELEC.
- D a requires the applicant for such permit to file a signed statement that TOTAL PERMIT T
A w $ he is licensed pursuant to the provisions Of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
E E o
¢ H $ thebasis for the alleged exemption.Any violation ofSeclion 7031.5 STORIES TYPE CONSTR.
a3 - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my Ci ployees 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(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Luw 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-
meatsarenot intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 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.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with ] ] 1:1 E] ]
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B, 6.00 ASSESSORS PARCEL NO.
and Professions Code:1'Ite Contractor's License Law does not apply
to an owner of property who builds nr inhpmvcs thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts I'orsuch projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I um exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
mason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
TION DECLARATION WATER TREATING EQUIP. 5.00
1�rc6JalLinl lf�oKlllu crtifcmc ofconsent m self-insum,
or a Certificate of Workers'Compensation Insurance,or a'certified ZONING ENG.SITE NO.
copy thereof(Sec 3800,Lab.Gl. -J--/01
Policy ere 00,La ny
O ❑ ertified copy is her fumishy4 ! FIRESPRINK ENERGY T24
z Z ;✓Certified copy is II with Y I Pemion division.
Q Applicant ! / MISC.- REFER TO ORD. Y ❑ NE] Y [] NE]
CCN C17RTIFICATE 01 EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z( This section need not be completed if the permit is for one TOTAL Y❑ IN Y CD N]
hundred dollars(S 100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL I. mit is issued.I shall not employ any person in any manner so as to
Ow become subject to the Worker Compensation Laws of California. BUILDING
Q. Date Applicant ALTER OR ADD TO MECH. 5.00
} Vr NOTIC17'f0 APPLICANT. If,after making this Certificate of 17x-
F Z emption,you should become subject 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 be decnmd revoked AIR HANDLING T
NG N 10=CF.M,) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLIOVER10=C.RM.) 6,00 SEISMIC FEE
I hereby affirm that there is u construction lending agency for EXHAUST HOOD ( IT"DUCT) 5.00
the performance Of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING I(G'IT 100,000 B.T.U.) 6.00
Lender's Name HEATING UNIT B.T.U.19.50
Lender's Address ELECTRIC
• I certify that I have read this application and stale that the above V E N TI LAT 1001- (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(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposesBOILER-COMP (Over t00,000BTU)SEE FEE SCH. MECHANICAL
.
(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 y in consequence of the yranlin (this peat Ni- MECH.CONT. LIC.NO. MECH.
-0
-v TOTAL d0 TOTAL
Signator (Applicant/Contractor ate p_� Z� 03 35
OFFICE COPY