14083 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
,BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
SoiLOiNG APPLICATION & PERMIT 140.83
ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
Q U m
OWNER.. PLAN CHECK VALIDATION
"ANE QTY. ELECTRIC PERMIT FEE
4 48<tO U ONE
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00 e-
✓�/ LIC.N [' C IGHTING FIXTURES 10.00/1.00 11-7
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS
Jo L10AA V' PNON PANELS t 10.00 16 - DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP), 20.00 d - PLAN CHECK FEE P.C.NO.
OP
ENGINEER
Lic.No. SIGNS TRANS. 3.00
AADD.ESOR
Ervc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIPEMP.METER OR POLE INS. 20.00
APPLICANT's MOTORS SEE FEE SCH.
ADDRESS
1,263 L JCl 52-ex SERVICE CHANGE 20.00 /O(
/ r
00 o LICENSED CONTRACTORS DECLARATION L
<u u 1 hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
2 w (commencing with Section 7000)Of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
zProfessions Code n Rlicense is in full for t
icen ❑ ❑
2 0`u�l Lse Number
G I-w Dateon
tractor
a Y f BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLA - INFORMATION
woA" ( MISC-- r REFER.TO ORD
; u I hereby affirm that I am exempt from the Contractor's License 4S/ n f _ - VgLUATION
1'LL04 Law for the following mason.(Sec.7031.5,Business and Professions PERMIT ISSU NCE" - 10.00 �-
mt Code:Any city orcounry which re quires a permit toconstrucq alter,
sea¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O¢ requires the applicant for such permit to file a signed statement that /� �` G TOTAL33 PERMIT TO
w$ he is licensed pursuant to the provisions of the Contractor's License
rii Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r0 the basis for the alleged exemption.Any violation ofSection 703 L$ -STORIES TYPE CONSTR.
by any applicant for a permit subjectsthe applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(E500)J:
❑ 1,as owner of the property,or my Employees with wages asBACK 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 ProfessionsDRAINS-FLOOR,ROOF,AREA, D. 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 5.00SO.FT.FLOOR AREA roTAL 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-11 NC.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 Other
prove 1,aso nee of sale.). INDUSTRIAL•WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ d 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.
and Professions Code:The Contractor's License Law does not apply
to anowner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conituctotfsl licensed Pursuant to -
theContmctor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKHRS'COMPBNSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofeonsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy th o IScys3�OJ+ .I.
Policy �Sm17gP
Q ❑ Certified copy is herb umished. FIRE SPRINK ENERGY T-24
Z 2 � Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
0 App, Or Y❑ N❑ Y ❑ No
~ r2 PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.c.
LU a CERTIFICATEOFSAI M N INS FROM WORKERS'
UJ _ COMPENSATION INSURANCE. PLG.CONTE. LIC.NO: PLG.
CL 0 (This Section need not be completed if the permit is for one TOTAL Y ElN❑ Y ❑ N(]
:D Z hundred dollars 1$100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workeri Compensation Laws of California. BUILDING
0 y Date Applicant ALTER OR ADD TO MECH. 5.00
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? 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 10J)00C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.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 IT 100,000 B.T.U.) 8.00 MICROFILM
3097,nder's .am f/d r
Lender's Name /V Al�1 G HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC !�
Lender's Address ./
Icertify that l 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 PLUMBING
ordinances and state laws relating to building construction, and 80ILER-COAF(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP loter 100,000STU)SEE FEESCH. 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,judgments, costs and expenses which CONST.TAX
may in any way accrue.against said City in consequence of lire PERMIT ISSUANCE 10.00
granting of this permit. MECH.CONT. LIC.NO. MECH.
p� TOTAL TOTAL
Signature o-ffAAp+plieant/Contractor )ale
OFFICE COPY