13174 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT 1 DENTI FICAT•ION/0 PERMIT NUMBER
RUIIDING APPLICATION & PERMIT
'Ooh, s v - S�.F f BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 13174
• .c
OWNER'S i PLAN CHECK VALIDATION
'ly" NAME QTY. ELECTRIC PERMIT FEE
LL �/ OC.V PHONE
CONTRACTOR OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
A/ E P� � 'D ND. 0131 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES 4.00
'ADDfl E55,y 'Ir
�3• t/ //7,0,a/,9Z pp PRONE �• OQ PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
.uc.No SIGNS TRANS. - 3.00
moo Ess ENS. 00 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLI MOTORS SEE FEE SCH.
ADDRESS E59
SERVICE CHANGE 20.00
0 o 1/7
0 LICENSED CONTRACTORS DECLARATION ( /`7/
< 5 u I hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANCE OAT
,HA "' (commencing with Section 7000)of Division 3 of the Business and
a a BLDG. ELECT. PLG. MECH.
H N 2 I'rofessimns CoAy,and r license is in full fora)' 1st pff•-l. ❑ ❑ ❑
2 O w-,/ License Class_(:_r2 _Lic.Numhe ff aa�
9 w t.` Dutc.f,�7-d's'�_Contractor
a m 5 BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
o a
w ; w H 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
a. 0 vs Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� - w Code:Anycity orcounty which requiresa permit toconstruc!,alter,
Qa ¢ 0 improve,demolish,Or repair any structure,prior ht its issuance,also ELEC.CONTR. LIG NO. ELEC.
aDLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$ he is licensed pursuant to the provisions of the Contractor's License 9f��
H i Q Law(Chapter 9(cco memcingwlth Section 7000)n f Division 3 ofthe
s 4 Business and Professions Code)or that he is exempt therefrom and PLUMBING PERMIT FEE
¢ H D 0 thebass for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant ton civil penalty
of not more than five hundred dollars($500),) ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the Structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of _
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 O ...FT.1100.AREA TOTAL ACREAGE
• himself or through de own employees,provided that such improve
mems o not intended his or offered employees,
or provided
that S the bolding GAS-EA,SVSTEM•11NC.40UTLETS 6.00 -'-
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00 RES IND CON PB Omar
.
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPR IN KL ERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner Of property who builds or improves thereon,and who LAWN SPRINKLER$nO ER 5 IEA.) 1.00
contracts for such projects with a controcmds)licensed pursuant m SEWER-SANITA <STO MEA,200f,/10.00 the Contractors License Law. 0 TRACT NO, PARCEL NO.
❑ l am exempt under Sec.-,[L&P.C.for this WATER HEATER W/VENT ' : ] 6.00
reason
Owner Date WATER SYS EMcI 5.00 `f'
ACC.DATE ACC.FILE N0.
WORKBRS'COMPENSATION DECLARATION WATER TREATING E U I', (IQ 5.00
I hereby affirm that I have a certificate of consent to self-insure, CI Y
or a certificaof Workers'Compensation Insurance,Or a cell icd ZONING ENG.SITE NO.
copy th,Jy�te yW3'o`ns
Policy N mpany -f✓�fi�� 2 r�Ti�N/�.%
Q ❑ Certified copy is hereby famished' FIRE SPRINK ENERGY T-24
Z Z ❑ Certifi o,���Rle Ilh city yy�nspection division.
O Applicem /'/> tJrtL/('/ MISC.- REFER TO ORD. Y ❑ N❑ Y N❑
CC rPERMIT ISSUANCE 10.00
� - CIiRTIPICATIi OP EXEMPTION FROM WORKERS' FLOOD ZONE A.L.u.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG, Q
CL Z( This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y[:] N❑
hundred dollars IS 100)or less I
U O I certify that in the performance of the work I'or which this per, DTV. MECHANICAL PERMIT FEE FEE SUMMARY
11 F mit is issued, I shall not employ any person in any manner so as to
O W
CL pp become subject to the Workers'Compensation Laws of California:
Date A licant ALTER OR ADD TO MECH. 5.00 BUILDING'
} tp NOTICE TO APPLICANT: If,after making this Certificate sa F:x-
? em vision you should become subject m the Workers'Ccomply with APPLIANCE 5.00 PLAN CHECK
provisions io the Labor Code, you must forthwith comply with FEE
U such provisions Or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency fur EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work dor which this permit is issued(Sec.
3097, HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Nam me HEATING UN IT(OVER ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I eerily 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 /Q
ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.Or 100,000 B.T.U.) 6.00
r hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP lover 100,000 BTU)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 accrue against said City in consequence of the
gmn[i f perm .�_ MECH.CONT. LIC.NO. MECH.
y .y
G.-17-,?7 TOTAL TOTAL
Ignature of Applicant/Contractor Data
OFFICE COPY