13666 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE ALL POINT PEN ONLY
i
BUhLDI NG PROJECT 1 DENTI FI N PERMIT NUMBER
BV1LD1N APPLICATION & P IT 13666
ADORE s IkePING -ELECTRICAL-PLUMBING-MECHANICAL
E+ TE✓GLS K
PLAN CHECK VALIDATION
"DTVDTV. ELECTRIC PERMIT FEE
_V
0p-r
I "
C cro �Q /� O UTLETS-SWITCHES-RECEP 10.00/1.00
,LIC. /3 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR a APPLIANCES-RESIDENTIAL 4.00
,1ppRE5 9' '
htq P N _7 PANELS 0.100A 0)/QQA 100090, 1 DATE OF APPLICATION
ARCHITECT V PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
Zip rrEMP. METER OR POLE 1S. 20.00
ADDRESS MOTORS FEE SCH.
ADDRESS
SERVICE CH N 20.00
woo LICLNSLD CONTRACTORS DECLARATION / 41k7
a v w I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(wmmenchlg witlt Section 7000)of Division 3 of the Business and p �-�1 BLDG, ELECT. PLO. MECH.
H D i Professions Cad• m y license is in full fore td Pzf'c '1}r�).MP �i__] ❑ ❑ ❑
¢ O� Licens ass Lic.Number_ /
9 w w Date COntracrnr-�
H ' s BUILDING PERMIT
¢ w¢ OWNER-BUILDER DECLARA'p10N ( INFORMATION
wcA " MISC.- REFER TO ORD
;u I hereby clthat I am exempt from the Contractor's License VALUATION
LL o ¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE x
r - Code:Any city or county which requiresa permit to construct,alter, C`.11101 CUIPLOD
2 ¢ FO improve,demolish,or repair any structure,prior to its issuance,also E C.CO NTH
- LIC.NO. ELEC.
a O u requires the applicant for such permit to file a signed statement that TOTAL / 9. PERMIT TO
w $ he is licensed pursuant to the provisions of the Contractor's License
Hifi Law(Chapter 9(commencingwith Section 7000)of Division 3 oftbe
ii o Business and Professions Code)rr that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ H the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
� by any applicant for a permit subjects the applicant ton civil penally ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not mom than five hundred dollars($5000.):
O 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole cont pensation,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 docs such work FIXTURES-PER TRAP 5.00 so.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
memsareno(intendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or hnprovemen(is sold within one year of Completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). RES IND CON PB Other
❑ 'I,as owner of the property,ant exclusively contmeting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
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(EA.) 1.00
contracts for such projects with a contractorts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,L&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATERSYSTEM5.00
ACC.GATE ACC,FILE N0.
�' Klrirg�S:)CO, I�1,5ATIONDECLARATION WATERTREATINGEQUIP, 5.00
I h ffu 1 h v IGcate of consent 10 self-insure,
or a certificate of Workers'C en aY n Ins u�nce,or a er'lified ZONING ENG.SITE NO.
copy fSe 0 J_ 11(l_f-�
Policy
erNom
opany
Q ❑ Certified o pyisbercby fur l fished. FIRE SPRINK ENERGY T-24
Z Z ❑ Cel-E 1 py 1 ' t I s n.
H O Applicants �' �-�'�- MISC.- REFER TO ORD. . y ❑ N❑ I Y ❑ IN E]
CCN C17RTIFICATEOF EXEMPTION FROM WORKIiRSM • PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L 1 COMPENSATION INSURANCE. PLG.CONTE. LIC.NO. PLG. y[:] N❑ Y CJ N E]9L Q (This section need not he completed if the permit is for one TOTAL
Z) Z hundred dollars 15100)ar less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued, I shall not employ any person in any manner so as to
O W , become subject to the Workers'CO inpensation Laws of California. BUILDING
.y Date Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of lite Labor Code, you must forthwith Comply with FEE
such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the Performance of the work ;or which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Leader's Name H EATI NG U N IT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.R or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon 'ho BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for 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 in any way accrue against said City n consequence of the PERMIT ISSUANCE 10.00
gr tinghispeL;it MECH.CONT. LIQ NO. MECH.
Ag(/^K� TOTAL TOTAL
Si Lure of Applicant/Contractor Date
OFFICE COPY
a