13150 Y ,4- APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY`J�
BUILDING PROJECT IDENTIFICATION PERMI NUMBER
BUIL q^� APPLICATION & PERMIT
v! / -" S'FE��,e, l, / r LX BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 13150
OwNEnRS cc.•.• (� PLAN CHECK VALIDATION
. " E /,/12 J O// HON GTV. ELECTRIC PERMIT FEE
L M/i�y I.PHONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1,00
" CONS 2� 3
uc.No. LIGHTING FIXTURES 10.00/1.00
/, T PPLIANCES-RESIDENTIAL 4.00
/4 O0'
�a UX PHONE PANELS 10,00 DATE OF APPLICATION
ORCHITEC PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0,
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00 '
ARCH.OR ENO. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00 .� n
APPLICANT - MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
w o O LICENSED CONTRACTORS DECLARATION y
< u UI hereby affirm that I am licensed under provisions of Chapter I ISSUANCE GATE
01 (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
iProfessions Cod ray(uA -erase is in full fore u 4
z o - Licenu C ss G Lic.Number_ ❑ 01 01
o m r„°, Date_ .-(.� Contrucmr
m s BUILDING PERMIT
w OWNER-BUILDER DECLARATION
X °; LL y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
VALUATT
FUNQ Lew forAnythe
countywhichng reason. c.requires a permit to construct,
Professions PERMIT ISSUANCE 10.00
Code:Any city or county it any requiters permit o its issuance,
alter,
re p improve,demolish,or repair any structure,prior m its issuance,also ELEC.CONTR. LIC.NO. ELEL.
O LL requires the applicant for such permit to file a signed statement that TOTAL
E
$ he is licensed.pursuant to ing provisions of the )mi'Dmlor's License 40 Buw(Chand Proeosions Code)or Section 7s exem tthe ono oftheo Business and Professions Code)or that he is exempt therefrom and OTN: - 2 PLUMBING PERMIT FEE
thebasisforthe allegedexemption.Anyviolation o toa cion malty " STORIESi ; � by any applicant fora permit subjects the00.): antroacivilpenaltyALTER-DRAIN&VENT-WATER (EA.) 5.00
of mat more than five hundred dollars(EEDO)J:❑ I,as owner of the property or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROU
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 SO,FT,FLOOR AREA TOTAL ACREAGE
• meets are not hrough
ownemployees,for sale.
If,however,
the
improve- GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
mems are not intended or offered for sale.If,ed that s the bwldin-
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 he did not build or im- BUILDING USE
prove for purpose of sale.). , INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB 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.
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 contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner - Date WATER SYSTEM 5.00 ACC.DATE "ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation,nsurag.y,oC ENG.SITE N0.
Lob.CJ. /T' 1 0
/��J•,I1�yf•Y� mpany-
O ptif p herelIy furnished.• FIRE SPRINK ENERGY T-24
Z Z Candied c is wl�0rr s�he city inspection division.
O Applicant A.L(L MISC.- REFER TO ORD. Y❑ N❑ Y❑ N
~ yPERMIT ISSUANCE 10.00
- CI?RTIFIC fE OF EXEMPTION FROM WORKERS' FLOOD ZONE A,LU.C.
W 1 'OMPF,NSATION INSURANCE PLG.CONTR. LIC.NO. PLG, ❑ ❑ O N❑
C' 0 (]'his section need not be completed if the permit is for one TOTAL Y N Y
:) Z hundred dollars($100)or less)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL F mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
a Datc Applicant ALTER OR ADD TO P& 5.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certitiemi,of Ex-
♦- T: emption,you should become subject to the Workers'Compensation APPLIANCE r..,s 1 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with - FEE
V such provisions or this permit shall be deemed revoked AIR HANDLING LINM IT 1 ,000 JO) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIYIOVER 10=C&MA 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD ( 'F 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Co.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name H EATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
. I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,0008_T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL Q�
above-mentioned property for inspection purposes.
(We)-agree to save, indemnify and keep harmless the City of MISC.• REFER TO ORD.
Cupertino against liabilities,judgments, casts and expenses which CONST.TAX
may any wa accrue against mid City in consequence of the PERMIT ISSUANCE 10,00
grant ng f[h mil. MECH.CONT. C.NO. MECH.
0-$ 2On OTAy�, o� TOTAL
Sign eof Applicant/Contractor Date ✓ �'
OFFICE COPY