13047 (2) tIAPPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT I DENTI FIC N PERMIT NUMBER
BUILDIN APPLICATION & P IT ^
ooREss K
r y L �� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 13 047
OWNER'S PLAN CHECK VALIDATION
NAME (,PJM e4aye 356-369 QTY. ELECTRIC PERMIT FEE
Ste. / PHONE 6
carvTRAcr Rs
MFOUTLETS-SWITCHES-RECEP 10.00/1.00
NAi. 1 r /1_.l
KJ �N{T LIC.
F`c.ND. /G JUrHTING FIXTURES 10.00/1.00
CONTRACTOR
ADDRESS
Cmlge.AI�o PPLIANCES-RESIDENTIAL 4.00
AD /
__
Lz PHONE _4S4-3&qfp1 JPANELS 10.00 DATE OF APPLICATION
ARcwrecTPANELS (OVER 200 AMP)
ENGINEER 20.00 PLAN CHECK FEE P.L.N0.
on
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS s MOTORS SEE FEE S
c.X[HLC. SERVICE CHANGE 20'0(f
JY r7
w o O LICENSED CONTRACTORS DECLARATION' n +� /0/
a u u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUQE ATE
Q w (commencing with Section 7000)of Division 3 of the Business and BLOC. ELECT. PLG. MECH.
r y i Professions Code,and my license is in full force and effect. 0❑ ❑ ❑ ❑
z 0,� License Class Lie.Number (�
0 H O Date Contructor /�/ /� /
BUILDING PERMIT
ac a w ¢ OWNER-BUILDER DECLARATION INFORMATION
s o a U MISC.- REFER TO ORD
X ;u_y I hereby aflrm that 1 am exemlit from the Contractor's License VALUATION $/FT.
wu0¢ Law for the following mason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.0575
mm Code:Any city or county which requiresa permit to construct,alter,
¢ ¢ Q improve,demolish,or repair any structure,prior to its issuance,also ELEO.CONTE. LIC.NO. ELEC.
O¢ requires the applicant for such permit to file a signed statement that TOTAL j� PERMIT TO
X $ he is licensed pursuant to the provisions of the Contractor's License
iii Law.(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe Tin E7
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
It r $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIU TYPE CONSTR.
w. by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as ggCK FLOW PROTECT. DEV ICE 4.00 OCC.GRauP 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 thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 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 O ha,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 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 conlracturts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lace exempt under Sec. ,B.&P.C.fnr Ibis 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
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec 3800,Lab C'
Policy No, CnmPS
0 ,❑ Certilied copYi hereby furnish FIRE BPRINK ENERGY T-24
Z Z ❑ Certified c py is file w th I city inspection division.
O Applicant ,,Q MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
m PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
CERTII'ICATE OF'FXF:MPTION I° OM WORKERS' ,
LU _ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CLO (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ IN
D Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f mit is issued,I shall not employ any person in any manner so as to
OW become subject to the Workers Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
>_ DO NOTICE TO APPLICANT': If,after making this Certificate of Ex'
F ? 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
V 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 10=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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.CJ.
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC °-0
Lender's Address f
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
�I hereby authorize representatives of this city to enter upon the
above-mentioned property for inspect' n purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to Save, indemnify • keep harmless the City of MISC.- REFER TO ORD.
Cupertino agJim,liabilities,judge n costs and ex nses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any it i City in cone ence f thegranting f IhMECH.CONT. LIC:NO. MECH.
TOTAL TOTAL
Signal o Applicant/Contractor 7L plate
OFFICE COPY