13544 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
r BUILDINiIPROJECT IDENTIFICATION PERMIT NUMBER
,BUILDIry[ _ APPLICATION & PERMIT
ADORE 5g' • . 13544
4 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
N co'B PLAN CHECK VALIDATION
NnmE PHONE QTY. ELECTRIC PERMIT FEE
s
CONTRACTOR Sjo
NnmE UTLETS-SWITCHES-RECEP 10.00/1.00
f
C(Af0 a uc.Na LIGHTING FIXTURES 10,00/1.00 -
CONTRACTOR
OONTRA TORa PPLIANCES-RESIDENTIAL 4.00
ADDRESV / a PHONE APANELS 10.00 DATE OF APPLICATION
ORCHITE PANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR' ADDRESS ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20,00 �j /
Woo LICENSED CONTRACTORS DECLARATION O/�7/,�'
a v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
z G w (commencing with Section 7000)of Division 3 of the Business and< y BLDG. ELECT. PLG. MECH.
H °i Professions Codepi m license is in full fort an effect. ❑ ❑ ❑
License ass Lia rector
9 m F w Date ff_�_Contractor '
Q y f J BUILDING PERMIT
M a OWNER-BUILDER DECLARATION
Ir: w U INFORMATION
a'xI;u N I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
ruoas Law forthe followingratiam.(Sec.7031.5,Business and Professions pERMIT ISSUANCE 10.00 VALUATION $/FT.
f w�f Code:Any city or county which requires a permit to construct,Eller,
Ix Ix> 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
n ° u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$a he is licensed pursuant to the provisions of the Contractor's License
Hi > Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
Is-° the basis for the alleged exemption.An
g p the
eapplica a toacion7031:5 STORIES TYPE CONSTR.
by any applicant fora permit dollars(he0).):ant(oacivilpena0y ALTER-DRAIN -WATER IEA.) 5,00
of not marc than five hundred Dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole 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(hereon,and who does such work FIXTURES-PER TRAP 5.00 60.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
meptsarcnotintendedorofferedforsale.If,however,the building / GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement 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.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PS Other
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
C3 1:1 C3 El El
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 contractorls)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORMEA.200ft/10.00 U TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-.B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner - Date WATER SYSTEM C2 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TR EATINr EQUIP, 5.00
I hereby affirm (hat I have a certificate of consent to selhinsum. 'v s
or a certificate of Workers'Compensation Insurance,or a certified '� ZONING ENG.SITE NO.
copy(hereof(Sec.3800,Lab.C.).
Policy No. Company_,0. _ p (a -
0 ❑ Certified copy is hereby furnished yUQ FIRE gPRINK ENERGY T44
Z Z ❑ Certified Py is filed w I tbl, ms h u division.'
O Applicant Ey _ MISC.- REFER TO ORD. Y[:] NE] Y C] No
CC LO CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.II.C.
W;> COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
1 0 (This section need not be completed if the permit is for one TOTAL e 0 Y❑ N F] Y[3 N
M Z hundred dollars IS 100)or less.)
U 0 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
F
LL U mit is issued,I shall not employ any person in any manner so as to
0 Edbecome subject to the Workers'Compensation Laws of California.
Q. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ 0 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 the labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
. CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10130DC.FM.) 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 for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI NG U N IT(0 V ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that 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-COMP(3H.P.Or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon clue 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, c.six and expenses which- PERMIT ISSUANCE 10.00 CONST.TAX
may In any way accrue agonist said CI consequence of the
grant Of this permit. MECH.CONT, LIC.NO. MECH.
TOTAL TOTAL
I Atumof App1cant/Contr or DaW
IOFFICE COPY