13948 .� APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
LD / BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
"OnDING APPLICATION & PERMIT 13948
!!
Ann. BUILDING/�s �cr
/ �/ /V (U BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
• NAME QTY. ELECTRIC PERMIT FEE
PHONE
CON TflgCTOR'S
NAM UTLETS-SWITCHES-RECEP 10.00/1.00
/ GF� .rvo. %PPLIANCES-
GHTING FIXTURES 10.00/1.00
CONTRACTORS RESIDENTIAL 4.00
A R r
a sTeff W PHONES ' PANELS 10.00 DATE OF APPLICATION
Of�Hy1' -O,66`J_ ^ A J Sn g PLAN CHECK FEE P.C.NO.
IVIGis. /yFAr C.. r./7T 7 PANELS (OVER 200 AMP) 20.00
LIC.NO. SIGNS TRANS. 3.00
aoon'ESS eec. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00r
APPLICANT'S •! MOTORS SEE FEE SCH. r
ADDRESS
SERVICE CHANGE 20,00
woo LICENSED CONTRACTORS DECLARATION "`••'
aL,U 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y (commencing with Section 7000)of Division f the Bus,nes and
r Z Professions Cod,�,�een icense is in full f BL❑DG:. ELECT: 1o,,PLG, MECH.
Z
o - License Cla f.:. Lic.Number
4 ,�„r w Date ComnmM
Ic w O E - ILDER DECLARATION BUIL G PERMIT
a o e. MISC.- - REFER TO ORD INFORMATION
X ; y I hereby affirm that am exempt from the Contractor's ,cense
H u o va Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
i Code:Anycity orcounty which requires a permit to construct,alter,
ED 2 <2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ,
-O 0 requires the applicant for such permit to file a signed statement that TOTAL PERM T TO
Whe is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
H $ the basis for the alleged exemption.Any violation of5eclion 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(85000.);
❑ 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"he structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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- GAS-EA.SYSTEM-1 INC.40UTLETS 6.00
menta are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 200 BUILDING USE
builder will have the burden of proving that he did not build or im . . .
RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
i 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 Contractors 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 contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
TRACT NO. PARCEL NO.
C3 tum exempt the Contractor's t u nde Low.
under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure, ZONING
or certificate of Warken'Compensation Insurance,or a certified ENG.SITE N0.
C. 800,Pahp. jr)
I' am adl 3/�•
Q ❑ title copyls h ere by furnished. FIRESPRINK ENERGY T-24
Z Z arti copyA filed s th th it i ecl,on dWY❑ N❑ Y ❑ NN[3sion' MISC.• REFER TO ORD.
"
O APPlican
~ w /Y r / W PERMIT ISSUANCE 10,00 FL000 zoNE A.L.u.c.
CC CERTIFICATE OF EXEMPTION FROM WORKERS'
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z( This section need not be completed if the permit is for one TOTAL Y❑ N[3Y C] No
hundred dollars(51001 or less)
U O I certify that in the performance of the work for which"his per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I dial not employ any Person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0 y Date Applicant ALTER OR ADD TO MECH. 5,00 BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate OFF.-
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 10DWC.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"he'work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Ce.C.).
Lenders Name H EATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address' ELECTRIC 8-
I certify that I have read Ihis application and state"het 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 construclion, and BOILER•COMPI3H.P.Or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTUI 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,j encs, costs and expenses which CONST.TAX
y in any way accrue ag s said City in consequence of the PERMIT ISSUANCE 10.00
g ming of this er MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL 0017
Styndture of App cant/Contractor Dat O
OFFICE COPY