13421/%PPLICANT TOe/ ��4/JJJ
ILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NG PROJ CT I DENTI FICATIO
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
_
13421
But- ,
AO E �J
L/
OW HIS
IN (/�]
PHON /'a
TY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
co R CTOR'S
NA
LIC. N f
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
c
l
PPLIANCES- RESIDENTIAL 4.00
y�TOR'
V PrIO
DATE OF APPLICATION
PANELS 16.06
ARCHITECT tPANELS
OR
ENGINEER
LIC. NO.
(OVER 200 AMPI 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.
AOORESS '
SPECIAL CIRCUIT 5.00
PFRMITIVALI DATION
EMP. METER OR POLE INS. 20.00
ZIP
r1 'f�{ -I
A!
xJ !L 31 I,'."_!'
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
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CIf,YA4{ CUI �rzn
' /ISSUANCE
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
DATE
(commencing with Section 7000) of Division 3 of the IIsi s a
Professions Co W -ii ''ense is in full fun
License Class Lia Number
-
BLDG.' ELECT. PLG. MECH.
❑ ❑ ❑
Dat Contractor
BUILDING PERMIT
OWNER -BU LDER DECLARAT ON
Thereby cthe ollo that I am exempt from the Contractor's License
Professions
Law fornycitllowingreywhich c. requires a perminess t to construct. alter,
Any mulish cor n pair any structure,
requires prior o its issuance,
improve, demolish, or repair any structure, prior m its issuance, also
improve,
requirese p foo such revisit to file a Signed Statement that
he is licensed pursuant to the provisions of the Contractor's License
INFORMATION
MISC.- REFER TO ORD
VALUATION
/FT.
PERMIT ISSUANCE 10.00Code
ELEC. CONTR. LIG NO.
ELEC.
TOTAL -
P RA71T TO
CITY. PLUMBING PERMIT FEE
I
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
ST RIESTV
CONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 5.00
by any applicant fora permit subjectsthe applicant toa civil penalty
of not more than five hundred dollars
O 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
BACK F LOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
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-
mentsarenotintendedorofferedforsalelf, however, the building
GAS - EA. SYSTEM - 1 1 NC. 4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that h e did not build or im-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (See. 7044, Business
GAS - EASYSTEM -OVER 4 IEA.) 2.00
. -
BUILDING USE
RES IND CON PB Other
❑ ❑ - ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
and I'mossions Code: The Cmamctors License Law docs nor 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
the Contmaor's License Law,
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
❑ I am exempt under Sec. ' ,R&P.C. lin Ibis
reason
Dam
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
ry?t OI PKI DECLARATION -
WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate orconsent to self -insure.
or a certificate of WorkeWc�
'Icopy thereof (Sea 3800,Policy
ZONING
ENG. SITE NO.
No. Com❑
Cerlific Ish
Certi d o y nspection division.
Applicant
FIRE SPRINK
v N
❑ ❑
ENERGY T 24❑
v N
❑ ❑
MISC. - REFER TO ORD.
CE 1 ICA'fli OF liXEMPTION PROM WORKERS'
PERMIT ISSUANCE 1000
FLOOD ZONE
A.L.U.C.
PLG. CONTH. LIC.NO.PLG.
TOTAL
COMPENSATION INSURANC17
(This section need not be completed if the permit is for one
v ❑ N❑
v ❑ N❑
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollar, ($100) or less.)
1 certify that in the performance of the work Ibr which this per-
mit is issued, I shall not employ any person in any manner so as to
became subject to the Workers' Compensation Laws of California.
Date Applicant
BUILDING
I r -
ALTER OR ADD TO MECH.IPA �.,5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
mption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be decried revoked.
APPLIANCE _ 5.00
PLAN CHECK
FEE
s
AIR HANDLING UNIT (TO dOgWe.F.M.)1 - 4.00
AIR HANDLING UNIT (OVER 109MC. F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) V!11IC15!00
HEATING UNIT (TO 100,000 B.T.U.1 8.00 �'
I hereby affirm that there is a construction lending agency for
the pr,f.rm.ncc of the work Ibr which this permit is issued (Sec.
3097, CmC.).
MICROFILM
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and slate that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) - 4.00
PLUMBING
9 !0 -
BOILER -CCIVIP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property or inspection purposes.
(We) agree to save, d mnify and keep harmless the City of
Cupertino age list' I[ie ,judgments, costs and expenses which
any ac ru a�ai est said City in consequence of the
mnY g ( s per 1 Aw
MISC. - REFER TO ORD.
CONST. TAX -
PERMIT ISSUANCE 10.00
M H. CONT. LIQ NO.
2
MECH.
TO
TOTAL
�9 j
nature ofA mlicant/Cmitronor all
OFF CE COPY