13470 (2) APPLI.DANT TO-FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BDILDING �C� 1 APPLICATION & PERMIT
ADDRESS
-)-1
l r0� '�� -^ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 13470
OWNER'S PLAN CHECK VALIDATION
NAME TY. ELECTRIC PERMIT FEE
(JQ(JyHONGLV J��/�j
oeTRAcro s
NAME nV OUTLETS-SWITCHES-RECEP 10.00/1.00
GI
CTL { u Luc,No.� S LIGHTING FIXTURES 10.00/1.00
CONTRNTRADDRESC7oRs
AAPPLIANCES-RESIDENTIAL 4.00
A
'
PANELS 10.00 DATE OF APPLICATION
aRCHITEC1 I PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO,
OR
NGINEE�
SIGNS TRANS. 3.00
A .
RC OR ENG. �OPECIALCIRCUIT 5,06 PERMIT VALIDATION
ADDRESS
Q EI CJY.INb zIP EMP.METER OR POLE INS. 20.00 QQ....J
APPLICANT'S MOTORS SCH.
ADDRESS
SERVICE CHANGE 20.00 Oj/�
w O o LICENSED CONTRACTORS DECLARATION . �� G(
a U I hereby affirm that I am licensed under provisions of Chapter 9 O ISSUANCE DATE
HA zw (commencing with Section 7000)of Division 3 of the Business and
G c O Y BLDG. ELECT. PLG. MECH.
H y i Professions C e,an y license is in full forc�.Zn 1
❑ ❑ ❑
z 0 w- License Chas Lia.Nu lH
o L F Date Conlr r
P f a BUILDING PERMIT
IS IS w OWNER-BUILDER DECLARATION INFORMATION
w; LL H I hereby affirm that 1 am exe m pt from the Co n t m '
ctors License MISC.- REFER TO ORD
a_ J Law for the followingreason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 �Q '_ VALUATION $/FT.
� - Code:Anycity orcounty which requires a permit to construct,alter.
a¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0.
wrC nquires the applicant for Such permit t0 file a signed situ Cment that TOTAL S� PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
Hii Law(Chapter 9(commencing with Section 7000)ofDivision3ofthe
Q Rusiness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r $ Ille basis for the alleged exemption.Any violation of Seclion 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500)):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.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
Cade:The Contractor's License Law does not apply to an owner of
property who builds Or improves Iltereon,and who does such work FIXTURES'-PER TRAP 5.00 50.FT.FLOOR AREA TOTALACR EAGE
himself or through his own employees,provided that such improve-
ments are not 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). IAL WASTE INTERRES IND CDN PB Omer
INDUSTRIAL . 30.00
❑ 1,as owner of the property,am exclusively contracting with ❑ El ❑ 0 13
licensed contractors to construct lire 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 of improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. - PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
SO p ereo
Po
4
O Certified copy Is hereby famr(ished.:'
z Z Cert CO yy��is fie w' r the cyy Pipe�I. n vision. FIRE SPRINK ENERGYTZ4
O Appllc,th", �A� LnAI._L,�`p MISC.- REFER TO ORD, v No , v E] No
CIiRTI E 4
~ va ?'1C' �R�T wO7tK PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C.
W - I
W COMPENSATION INSURANCIiPLc.CONTR. LIC.No. PLG.
D. O (This Seclion lived not be completed if tile permit is for one TOTAL Y C1 NO Y❑ N El
D Z hundred dollars(S 100)or less)
V O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
OWbecome subject to the Workers'Compensation Laws of California.
y - DateApplicantBUILDING
>_ N NOTICE TO APPLICANT: If,after making this Certificate:of lig- ALTER OR ADD TO MECH. 5.00
F ? emptim,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C.) 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 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CP.C). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT(OV E R 100,000 B.T.U.)9.50 / C
Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county BOILER•COMP(3 H.P.Or 100,0008.T.1A) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon lire
above-mentioned property for inspection purposes. BOILER-COMP (Over 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 :rad expenses which PERMIT ISSUANCE '10.00 CONST.TAX
may in any way accrue against said�Cdy in consequence of the
gra of this permit. ` MECH.CONT. LIC.NO. MECH.
i turc of Applicant/Con to D to
I� oTAL TOTAL
OFFICE COPY