The URL can be used to link to this page

13884 APPi_ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 1 78U1 LDLNG PROJECT I DENTI FICATION PERMIT NUMBEI!. BUILDING APPLICATION & PERMIT 13884 ADDRESS �tOOu wc1� /La BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 9 OWNER'S PLAN CHECK VALIDATION NAME ` QTY. ELECTRIC PERMIT FEE CONTRACTORS '(0 OUTLETS-SWITCHES-RECEP 10.00/1.00 6d N OLIGHTING FIXTURES 10.00/1.00 s('. CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00 AVDREss �p/ k # PHONE �cysb PANELS 10.00 DATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO, OR ENGINEER LIc.Na. ISIGNS TRANS. 3.00 ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VA LOCATION ADDRESS ZIP TEMP. METER OR POLE INS. 20.00 ADDRESS rS MOTORS �jQ®SEE FEE SCH. LD( SERVICE CHANGE 20.00 F O O LICENSED CON'T'RACTORS DECLARATION < E,w 1 hereby affirm that I :no licensed under provisions ol'Chapter 9 ISSUANCE DATE N a w (commencing with Section 7000)of Division 3 of the Business and Ino BLDG, ELECT. PLG. MECH. F D z Professions Code,and my license is in full force and effect �itil !1t Cone ❑ FV1 ❑ ❑ z o m- License Class is (J Lie.Number�D 7�j l 5 - Q H t Date��lff1-.$-'�( Contract., a y BUILDING PERMIT ¢wOWNER-BUILDER DECLARATION INFORMATION wu H I hereby affirm that I am exempt from the Contrvctor's License MISC.- REFER TO ORD VALUATION S/ET. ..N j Law for the following reason.(Sec.7031.5.Busincoand Professions PERMIT ISSUANCE 10.00 rJ Code:Any city or county which requires a permit to construct,alter, y� pQ Q 2 Improve,demolish,Or repair any structure.prior to Its Issuance.also ELEC.CONTR. LIC.NO. ELEC. T i - D ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO wm" he is licensed Pursuant to the provisions of the Contractor's License E GT rii Law.(Chapter 9(commencing with Section 7000)of Division 3 ofthc - Q Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE f ¢ O STORIES TYPE CONSTR. ¢ 5- the basis for the alleged exemption.Any violation of Section malty u; � by any n,mthan lava hundred dollar,the applicant IDS civil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not nurse than five hundred dollars(85 ❑ as owner of the property,or my employees employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS their Scale compensation,will(S the work,andBusiness the structure is nut intended o, offered for sale (Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Corfu:The hContractor's build,or License Law dues not who to an owner of property who builds or improves Dmreon,and who docs such work FIXTURES,PER TRAP 5.00 50.FT,FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve. GAS or SYSTEM-I INC.4 OUTLETS 6.00 mems are not intended or offered for sale.If.however,the building or improvement is sold within one year of completion,Dm owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING 115E builder will have the burden of proving that he did not build or it.- RES IND CON PB Omer prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 D 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. add 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 SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO. PARCEL NO. the Contractor's License Law. ❑ I am exempt under Sec...B&Tic for this WATER HEATER W/VENT 6.00 mason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0, WORKERS'COMPF.NSAI'ION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that 1 have a certificate of consent In self-insure. ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or�a certified copy therepf lSec.38 LI= s uCe� �.-LMS Policy No. a� C3 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24 z_� b anttifieJ copy is filed with the city inspection division. MISC.- REFER TO ORD. Y❑ N❑ Y❑ N❑ O APPlicanl F-- wPERMIT ISSUANCE 10.00 FLOOOZONE A.L.O.C. CO = - CERTIFICATE OF EXEMPTION PROM WORKERS' Ill COMPENSATION INSURANCE PLG.CONTR, LIC.No. PLT. Y❑ N❑ Y ❑ N❑ d O 1'fhis section need not be completed if the permit is for one TOTAL Z) Z hu nd rad dolls rs IS 100)or Ico,) U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY UL F- mit is issued,I shall not employ any person in any manner so as to O W become subject to the Workers'Compensation Laws of California. BUILDING Date Applicant ALTER OR ADD TO MECH. 5.00 } h NOTICE TO APPLICAN'C If,alter making this Certificate of Ex- F_ ? eruption,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 1Q000C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0=C.F.M.) 6.00 SEISMIC FEE I 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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC L � Lenders Add mss ' 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 BOILER-COMPM H.P.or 100,000 B.T.U.) 6.00 PLUMBING ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTUI SEE FEE SCH. MECHANICAL above-mentioned property for inspection purposes. WE) agree to save, indemnify and keep harniless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which CONST.TAX may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 ran n Of this trmil. MECH.CONT. LIC.NO. MECH. g /`�� ` �� IQ� TOTAL TOTAL Signature of Applicant/Contracto Dates OFFICE COPY