13533 APPLICANT TO FILL IN IP2FORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDI NG PROJECT I DENT]FICATION PERMIT NUMBER
eUILDI"` 2f52S RDDINGi'ON CT APPLICATION & PERMIT
A°DRESS 13533
BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
WNER's 1.;. '•.;,, 'w"LE PLAN CHECK VALIDATION
Ave JOHN 5NER1 KoR.oNpy I]TV.' '•;"C. ',' •.ELECTRIC PERMIT„ :�'�'" 'FEE
1RONE1N6-58o7 '• •p � I .• 1 CONTRACTOR'S
NAME OUTLETS-SWITCHES-RECEP 10,00/1.00
LIC NO I LIGHTING FIXTURES 10.00/1.001
CONTRACTOR'S +
ADDRESS APPLIANCES-RESIDENTIAL 4.001 t
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT — '- '-' "— — — PLAN CHECK FEE P.C.NO
oR (PANELS (OVER 200 AMP) 20.00
ENGINEER
__ __ _ 41C.NO. ___ __ _SIGNS TRANS. 3.00 OR ARC ENG. SPECIALCIRCUIT 5.QQ i PERMIT VALIDATION
A000ness
ZIP EMP,METER OR POLE INS. 20.00
APPLICANT'$
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.001 1 1. J
w O 0 LICENSED CONTRACTORS DECLARATION /� /�/
au I hereby affirm that I am licensed under provisions of Chapter 9 1 -
2 w ISSUANCE DATE
H ¢ H fcommionsCde, Section 700e iiDrvl for 30(the Business and BLDG. ELECT;( PLG. I MECH.
H h z Professions Code,and my license Is in full force and effect 1 ❑ ❑ ❑
Z O m — License Class vI o Number L
I-w C
Dale Contractor
¢w a OWNER-BUILDER DECLARATION 1 ; 3�UILDING'PERMIT.
w °° sa MISC.— REFER TO ORD ts••—faS'.L?INFORMATION.;.;:
; N I hereby affirm that 1 am exempt from the Contractor's License VALUATION I $/FT.
u. O¢ Law for the RY[]owing r coreason.(Sec. uires a,Busmessand Professions 10.00 1
Code' e, m or count PERMIT ISSUANCE 7"
iw>f y y county requires permit to ELEC.CONTR. LIC.rvO. I
ir z ¢° improve,demolish,or repair any structure,poor to its Issuance,also I ELEC
m u requires the applicant for such permit to file a signed statement that TOTAL
° w he is licensed pursuant to the provisions of the Contractor's Lire"L. 1 PERMIT TO
r z i Law(Chapter 9(commencing with Section 7000)ofDwrsionJ of the Iu.l,j _ -x. ).: ., 'w; ".:C'�+ /
m o Business and Professions Code)or that he is exempt therefrom and QTY.' ?<. 9+ PLUMBING PERMITw y,:` 4FEE 'I 3
ec the basis for the alleged exemption.Any violation of Sect,.n 7031.5 - I`S1"a:n'.ter. .r,:C•n!`."-ly.'�-'t! d.^Y'I'sf a^ °'',5. 1 STORIES "TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty l• (ALTER-DRAIN&VENT-WATER (EA.15.00 1
of not more than five handled dollars 15500)).
X 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 I
their sole compensation,will do the work,and the structure Is not I OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions IDRAINS-FLOOR,ROOF,AREA,COND. 5.00 1
Code.The Contractor's License Law does not apply to an owner of
property who builds or Improves thereon,and who does such work IF IXTUR ES-PER TRAP 5.00 1 $0.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 I 1GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 1
• or Improvement Is sold within one year of completion,the owner- r
bwlder will have the burden of proving that he did not build or Im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.001 I BUILDING USE
prove for purpose of Sale.), RES IND CON P DOE,
❑ 1,as owner of the property,am exclusive) I INDUSTRIAL WASTE INTER. 30.001 1
0 p Y. y ,7044,Ong wRh 11 El 11 cl 11
licensed contractors: construct the project(See,7044,Business LAWN SPRINKLERS-1 INC5 V.B. 6.001 I ASSESSORS PARCEL NO.
and Professions Code:The Conbuilds Y License Law does not apply
to tr owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 1
contracts for such projects with a conlractorls)licensed pursuant I. SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. I TRACT NO PARCEL NO.
❑ la eze pt un er Sec. a&PC for
.,t
reason WATER HEATER WIVENT 6.001 1
\ _ _
J'Owner _ Date WATER SYSTEM 5.001 1 ACC.DATE ACC.FILE NO.
WO R K E RS'CO PE NSATIO I DECLARATION WATER TREATING EQUIP, 5.001 1
1 hereby affirm that 1 have a certificate of consent to self-Insure.1 1I 1 ZONING ENG SITE NO.
or a certificate of Workers'Compensation Insurance,or a cerullr 1 _ _ 1
copy Thereof f5ec.3800,Lab C.).
Policy ND. ComPam,_
0 ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city Inspection division. 1 Y N� Y 1] N]
O Applicant (MISC.- REFER TO ORD.
y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.001 1 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 O (This Section need not be completed If the permit N for one I TOTAL I Y 0 N Y 1] N❑
0 Z hundred dollars IS 100)or less) " �a, '_• y;:`,) Vie.,• - y. *•c@.1 FEE'
O 1 certify that in the performance of the work for which this per +..•-„ —LL FEE S_UMMARV.f=71
LL F not is issued,I shall not employ any person In any manner so as m �ry' '•"MECHANICAL PERMIT•.f:Tl (�; FEE _ _ .- $c'..;I
U become subject to the Workeri Compensation Laws of Cahfomia.
O w Date A licant BUILDING .Sa
} H NOTICE TO APPLICANT- If,after making this Certificate of Ex I , ALTER OR ADD TO MECH. 5.00 1
f.. Z emption,you should become subject to the Workers Compensation APPLIANCE 5.001 1 PLAN CHECK
provisions of the Labor Code.you must forthwith comply wit..I FEE J
C„1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=QF.M,) 4.001 1
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000 C.F.M.) 6.001 1 SEISMIC FEE
I hereby affirm that there u a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.001 1
the performance of the work for which this permit is issued(Sec MICROFILM
3097,CIv.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nam- (HEATING UNIT(OVER 100,000 B.T.U,19.50 1 ELECTRIC
Lender's Addre-
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 I
Information is correct. I agree to comply with all city and county BOILER•COMP(3 H,P.Dr 100,0008.T.U.1 6.00 PLUMBING
erdinances and state laws relating to budding construction, and 1
"•l hereby authorize representatives of this.clty to enter upon the
above-mentioned property for Inspection purposes. BOILER-COMP (Over 100,000 BTU(SEE FEE$CH. 1 MECHANICAL
(We) agree to save, indemnify and keep harmless the City of I MISC.- REFER TO ORD.
Cupertino against habllities,judgments, costs and expenses whin' PERMIT ISSUANCE 10.00 1 CONST.TAX
may in any way 4ecrue gams Id Oly m consequence of the 1
g [ing Ithrs tie [. �� MECH.CONT. LIC.NO. MECH
8 1 I TOTAL TOTAL
nature of Applicant/Contractor / D e •+v �..�
OFFICE_COPY