13588 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
LAIN Lc APPLICATION & PERMIT
=�R=ia3se�b /E t 13588
2� COV1� BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
Call S PLAN CHECK VALIDATION
NAME 1 QT V. ELECTRIC PERMIT FEE
e,1 6 Q te rwp �PHDN —
NNTRACT RA OUTLETS-SWITCHES-RECEP 10.00/1.0097
I NAME
A LIC.NO. LIGHTING FIXTURES 10.00/1.00 302
ADDRESS APPLIANCES Marys I PPLIANCES-RESIDENTIAL 4.00
CONTRAS •eW - `` �1LI
I (J Nv/f TONE -4V PANELS 10,0Q DATE OF APPLICATION
ARCHITECT —PANELS (OVER 200 AMP) 20.00 - PLAN CHECK FEE P.C.NO,
OR
WEER 0 j
U inI,l�-ALIC.No. SIGNS TRANS.' - 3.00
ADDREESSSA •G ARCH,00 ENG. W-DOd Cl '1y, SPECIALCIRCUIT S,QQ PERMIT VALIDATION
(0 1 QIP TEMP.METER OR POLE INS. 20.00
APPLICANT Na 1 MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
O o o LICENSED CONTRACTORS DECLARATION
r
a Z w I hereby affirm that I n licensed under n 3 Of the of Chapter 9 Pilo ISSUANCE DATE
y G (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
w i� Professions Co F,of ry license Is in full fin al 1 ❑
Z i w o Licen Ias Lic.Numbc (; '/ F-1 El
a fDate Commctor
¢ m g ..n 0 BUILDING PERMIT
IS Ic w u OWNER-BUILDER UILDER DECLARATION INFORMATION
w3 e N 1 hereby affirm that I am exempt from the Contractor's License' MISC.— REFERfiO.ORD
uo¢ Law for the following mason. 7031.5,Businessand Professions PERMIT ISSUANCE 10.00 UVALUATION $/FT.
� — � Code:Any city or county which requires a permit to construct,alter,
IS
IS Q 0 improve,demolish,Or repair any Slrn011lfe,prior to its issuance,also ELEQ CONTR. LIC.NO. ELEC.
O LL requires the applicant for such permit to file'a signed statement that TOTAL t0 PERMIT TO
E
$ he is licensed pursuant to the provisions of the Contractor's License '
rzr
Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe
4 o Business and Prolessions Code)or that he is exempt therefrom and QTY: , PLUMBING PERMIT FEE
IS [he basis for the alleged exemption.Any violation of Section 7031.5t- STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicanton civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(1500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
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
• properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve GAS-EA.SVSTEM-1 6,00
meats are not intended or offered for sale.If,however,the building
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 lie did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pe Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ 0 0 11
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 property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contmetods)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.—,B.&P.C.for Ibis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC,FILE N0,
WORK E:RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsenl to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
eoI(See.3800,Lab.CJ.�.�+ �s�
Policy o. Company %!�I r r a LTIl'LS•
0 , 0 Certified copy is hereby furnished. FIRE SPRINK ENERGY TZA
❑ Certi ' [I file aHth 1 cl (rlspection division. MISC.- REFER TO ORD,
F Q/ leJ/I111 �J,_1� ft Al V [] N� V � N�
H L'fi f.T E00I TON FROM WORK ERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.0 C.
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 2
(This section need not be completed if the permit is for one TOTAL YE] N
N Y❑
hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I— mit is issued, I shall not employ any person in any manner so as to
0 W. become subject to the Workers'Compensation Laws of California.
Date A licant BUILDING
a pp ALTER OR ADD TO MECH. 5.00
} N NOTICE:TO APPLICANT": If,after making this Certificate of EX.
? Cellih n,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..1 such provisions or this permit shall be deemed revoked. .AIR HANDLING UNIT(TO 10,000C.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOC.EM.) 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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.CJ. .
Lender's Name HEATI NG UNIT 100,000 B.T.U.)9.50 /
Lender's Address _ ELECTRIC /lip ,—•�
0 1 cer0fy that I have read this application and state tllm the above VENTILATION FAN (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-ODMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon tilt
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCM. 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 of the
a g of this Pawll. �z MECH.CONT. LIC.NO. MECH.
8 / TOTAL TOTAL
gn of Applicant/ ractor Daze
OFFICE COPY