14210 APPLICANT TO FILL IN INFORMATION VVITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BDILpINc APPLICATION & PERMIT 14210
ADDRESS
/570 , Gp /7 BUILDING- ELECTRICAL-PLUMBING- MECHANICAL
OWNER'SPLAN CHECK VALIDATION
ELECTRIC PERMIT K 'fir .FEE.-
CONTRACTOR
EE.CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NA E
G NO �7'lS.3 f LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
Ap RE/55 y
�7 �j PHONE ��� PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
OR
ENGINEER
LIC.NO. ISIGNS TRANS. 3.00
ARCH.08 ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
zIv EMP. METER OR POLE INS. 20.00
APPLICANT'S
/DpREss MOTORS SEE FEE SCH.
;GA�Cr6$✓�T SERVICE CHANGE 20.00
O¢ i l I13 I g /�/
l
'02 LICENSED CONTRACTORS DECLARATION
rt v v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
r a i (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG MECH.
r o z
Professions Cod•In 1!r license is in full for -7
O ❑ ❑
, O a- License ss /O Lic.Numble(r�/ /�/!>J.3
wF w Date - Contracm
BUILDINGjPERMIT,s,;.;Y:
w o OWNER-BUILDER DECLARATION y, - ,y
3 LL H 1 hereby'affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD V INFORMATION?; T.
a.o¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 - 'VALUATION SIFT.
- - Code:Any city or county which requiresa permit to construct,alter,
[ C Q O Improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. ELEC
I
O C requires the applicant for such permit t0 file a signed statement that TOTAL PERMIT TO
E:
m he is licensed pursuant to the provisions of the Contractor's License
u, r Law(Chapter 9(commencingwuh Section 7000)of Division 3 ofth a'r ,� z d,N.tif. I 4 ''1 + S L`I
a Business and Professions Code)or that he is exempt therefrom d CITY IL?t I .. R PLUMBING PERMIT. t '*. FEET,( 111
¢ r m the basis for the alleged exemption Any violation of Section 7031 5 :LTE �'$L ,.r1) S .v C vh. . Nv-! -e- A I:.•x'a*,,� STORIES TYPE CONSTR.
d ; - by any applicant for A permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sale 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
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work a FIXTURES-PER TRAP 5,00 -so,FT.FLOOR AREA TOTAL ACREAGE
^-^•.'y hon (for through his own employees.provided that such improve- / GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 .E
• meets 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 BUILDING USE
builder will have the burden of proving that hC did not build or im- RES IND CON PB Omer
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively'contracting with ❑ ❑ E] El El
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 whoLAWN SPRINKLERS-OVER 5(EA-1 1.00
su
contracts forsuch projects with a contractods)licensed pursuant m SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sec. .B.SP.C.for this WATER HEATER W/VENT 6.00 �-
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKFRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self-in sura, ZONING ENG.SITE NO.
or a certificate of Workers'Comp tion Insurance,or a certified
Copy th S i 0 Lab.C.) &nom
Policy��aCompany
Q ❑ 'ertdied copy'is hereby hmished FIRE BPHINK ENERGY T-24
Z Z }QCertifi co y s fil- with <he cit 'nspection division. MISC.- REFER TO ORD. Y N Y N
O Applicant-WLJ ❑ ❑ ❑ ❑
fLy CERTIFICATF.OF EXEhIPTl0 N1�ROM WORKERS' PERMIT ISSUANCE 10.00 A.L.0 c.
LU >_ COMPENSATION INSURANCE P .CONTR. /�,, � {/❑C.ACT, PLG.
EL O (This section need not be completed if the permit is for one �QL 4W,669 S3 TOTAL -� Y ❑ N❑ Y ❑ N❑
Z) Z hundred dollar,(S 100)Or less.) tx •�e t :.5.: - -FEE SUMMARY
0 O 1 certify that in the performance of the work for which this pe OTY'. 1 •MECHANIC_AL PERMIT FEE `
IL H mit is issued,I shall not employ any person in any manner so as to -
O w becomesubject to the Workers'Compensation Laws of California. M I BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} W NOTICE TO APPLICANT: If,after makinF'this Cert ifican•of Ex-
F Z emption,you should became subject to the Workers Compersmion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this penfiit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 I SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perfoanunce of the work for which this permit is issued(Sec. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 I
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state lre
aws lating to building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 6.00
• hereby authorize representatives of this city to enter upon the BOILER-COMP (Over t00,0008TU1 BEE 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 PERMIT ISSUANCE 10.00 CONST.TAX
may is any way accrue against said City in consequence of the
got tispymit , MELH CONT C N0 MEC
RTOT"` TOTAL
Signature of Appfcanili-ma iram Date
OFFICE COPY