13149 (2) 1 f 3,APPI,.1.CANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN oder " 35-
BU I LDING PROJECT I DENT[FICATION PERMIT NUMBER
Bolt ING APPLICATION & PERMIT
+
TV3SEE6 CT' BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 13149
OWNER'S L N PLAN CHECK VALIDATION
•
la-
a- ",+ 5011DNE QTY. ELECTRIC PERMIT FEE
CONTRACTORS ,J( �+�-2 UTLETS-SWITCHES-RECEP 10.00/1.00
�/ AIR C01 ua No� 3 LIGHTING FIXTURES 10.00/1,00
CONTRACTOR'SJ(r/ PPLIANCES-RESIDENTIAL 4.00
A 55 OX I4V D / '
PHONE PANELS 10.00 GATE OF APPLICATION
ARCHIT i ,L PANELS (OVER 200 AMP) 2O.OD PLAN CHECK FEE P.C.NO.
on
ENGINE R
- LIC.NO. ISIGNS TRANS. 3.00
ADDRESS ENG' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
zlv TEMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N r h (commencing with Section 7000)of Division 3 of the Business and BLDG. 'ELECT. PLG. MECH.
F h z Prafessions Code d fpnse is in fall fore I ..4J
z D a - License C ss� ✓ Lia Number
9 o r w Date Contractor_ .
al y F J BUILDING PERMIT
¢ a OWNER-BUILDER R-BUILDER DECLARATION RATION
IS
a W u INFORMATION
Od MISC.- REF ER TO ORD
X 3 LL w I hereby Rohit that 1 am exempt from the Contractor's License
wO¢ Law for the following reason.(Sec.703L5,tlusinessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
r Nye Code:Any city or county whichrequiresa permit to construct,after,
s ¢ ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. '
IS
-m LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT T
u he is licensed pursuant to lite provisions of the Contractor's License
Hit Law(Chapter 9(corn meucing with Section 7000)of Division 3 ofthe '
a Business and Professions Code)or That he is exempt therefrom and OTY. - PLUMBING PERMIT FEE
¢ r $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500y):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE L00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve
cents are not intended or Offered for It.If,however,lite building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
ar improvement is sold within one year of completion,the owner- GAS-EASYSTEM OVER 4 (EA.) 200
builder will have the burden of proving that he did not build or I'll- . - .
I'll- . BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with E] ❑ [:] C] ❑
licensed contractors to construct tiro project(See. 7044,.Rusiness 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 Property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,R&P.C,for this WATER HEATER W/VENT 6.00
masmi
Owner Dale WATER SYSTEM 1 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm.that I have a certificate of consent to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation In urance,or certified
,&I,�,Xp�/��q SRO J. IEW r
y.f-7�-f(o tr, r' y esia
Q ❑ �rTiDed copy_IS he re fum r FIRE SPRINK ENERGY T 24
Z Oertifiud copy is wi I I/,.(.�d pection division. MISC.- REFER TO ORD.
Applicant r-_/-1'lGs Y N Y N
y CE RTI FICATH OF iXEMPTION PROM WORK Ii RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UXD
L COMPENSATION INSURANCE PLG,CONTR. LIC.NO. PLG. v N v N
CL Z (This section need not he completed if the permit Is for one TOTAL
hundred dollars IS 100)ar IcssJ
U O I certify that in the performance of the work for which this per CITY MECHANICAL PERMIT FEE FEE SUMMARY
IL F- mit is issued, I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California. BUILDING
d Date Applicant ALTER OR ADD TO 5.00
} W NOTICE TO APPLICANT: If,after making this Certificate of 1: TER
Z emption,you should become subject to the Workers'Compensation APPLIANCE tCD )) 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply will FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1 PW C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(QVCR10= 6.00 SEISMIC FEE
I hereby affirm that there is aconstraction lending agency for EXHAUST HOOD WITH ❑ 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.), HEATING UNIT(TO 118, 00 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U. 9.50
Lender's Address ELECTRIC
I certify that I have read ibis application and stale that the above VENTILATIONFAN (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-OOMP(3H.P.or100,000B.T.U.) 6.00
Hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL 7�
Hereby authorize
property far 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 CONST.TAX
may m an way 'rue,against said City in consequence of the PERMIT ISSUANCE 10.00
gmntin his p t. MECH.CONT. LIC.NO. MECH.
D ' TOT" �O TOTAL
Signn[ur fA li ant/Contractor Date
OFFICE COPY '