13824 Af'P I A Tb FILLUIN INFORM ION WITHIN RED LINES - USE BAL I POINT PEN ONLY
BU LDI NG PROJECT I IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERM 13824
...REss I L^ _
G V BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
• NAME OTY. ELECTRIC PERMIT FEE
ATAA�a PHONE
rvTRACTORs OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
t D,V}' y LIC.No. I6 ILIGHTING FIXTURES 10.00/1.00
CONTRACTORSS^N�`/�- PPLIANCES-RESIDENTIAL 4.00
ADDRESS
T br 5F HONE / PANELS 10,00 DATE OF APPLICATION
ARCHITECT
AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200
ENGINEER
LIC.rvo. SIGNS TRANS. 3.00
ARCH.OR ENG. 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. '-4 �J
ADDRESS
SERVICE CHANGE 20.00 - ��i0/C�
a o LICENSED CONTRACTORS DECLARATION D S b' O
u w I hereby affirm ;hat I am licensed under provisions of Chapter 9 aN d� -_ 6'R-D ISSUANCE DATE
H < H (cot..nume ng with Section 7000)of Division 3 of the B,H ness and a+-/ BLDG. ELECT. PLG. MECH.
A w z Professions Code,and my license is in full fore a flet Z .. ❑ trT
z o,4- License Cie �--�/4(7 Lic.Number r- qq frl��INAI✓LG L ❑ ❑
0 _0 Datel...���Contractor_ .' z
r uBg SQ/0 r r BUILDING PERMIT
¢ w u OWNER-BUILDER DECLARATION `( INFORMATION
0 a- MISC.- REFER TO ORD
X 3 a.y 1 hereby affirm Ili at 1 am exempt fmm lie Contractor's License s--1 VALUATION $JET.
HLL0 Law for the following reason.(Sec.7031.5,11usinnssandl'rofessionsPERMIT ISSUANCEtl n� liU,s"- 10.00 ,0 '
Code:Any city or county which requires a permit to construct,alter,
2 W.Q 0 improve,demolish,or repair any structure,prior to its issuance,a15U ELEC.CONTE. CLIC.NO. ELEC. 2
O ¢ requires the applicant for such permit to file a signed statement that TOTAL v PERMIT TO
o
n
he is licensed pursuant to the provisions of the Contractor's License TYPE CONSTR.
STORIES
Hii Law(Chapter 9(commencingwith Section 7000)ofDivision 3ofthe G�lG �
Q Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
F S D
¢ H$ the basis for the alleged exemption.Any violation of Section 7031.5
w. by any applicant for a permit subjects the applicanllo a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500)J:
❑ 1,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 docs not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5,011 50.FT.FLOOR Afl EA TOTAL ACREAGE
• himself re through his own employees,provided that such Improve-mems o not intendethrough
or employees.ffered for rae. ided that
such
building GAS-EA.SVSTEM-l1NC.40UTLETS 6.00
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 he did not build or im- RES IND CON PB Omer
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ [,as owner of the property.alt exclusively contracting with El El ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCELNO.
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 contractods)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
Cl I am exempt under Sec..,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACG DATE AUG.FILE U.
WORKF-RS'COMPF-NSA'TION D17CLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certif¢ate ofconsent;o self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof lSec.3800,LaHCAl
PV(
rc No. Company e-AlimI
Q Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified coy is ❑led with I e city jnspeetiolt division. MISC.- REFER TO ORD. y❑ N❑ y C] NE]
�C��
CT PERMIT ISSUANCE 10.00 FLOOD zorvE A.L.u.c.
CC C0 CIiRTIFICOP EXEMPTION FROM WORKERS'
UI > COMPIiNSATION INSURANCE PLG CONTR. LIC.N0. PLG. Y❑ N❑ V ❑ N❑
CL 0 (This section need not he completed if the permit is for one TOTAL
Z) 2 hundred dollars IS 100)or less.)
C� O 1 certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,I ,all no;employ any Person in any manner so as to
Q w become subject to the Workers'Compensation Laws of California. BUILDING
Unite-Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE 70 AITLICANI': If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workeri Compcnsatlon APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you mus; forthwith comply with FEE
U such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 1QOODC.FJV0 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10I000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a to lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CD.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
. 1 certify that I have read Dtis application and uu¢that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree;o comply with all city and county PLUMBING
nNinances and slate laws relating to building constru Lion, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Iiabili;ies,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
May i any w y accr ensl said Cil in consequence of the
mnlin of this ernril MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature of Applicant/Contractor a;c P
OFFICE COPY