13823 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I ROJECT IDE TLFIC PERMIT NUMBER
BDILDIN , APPLICATION & PERMIT
noon C � `
L BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNERS PLAN CHECK VALIDATION
13823
NAME CITY. ELECTRIC PERMIT FEE
L� / PHONE
NAMERncroRs F/GLTP(6 UTLETS-SWITCHES-RECEP 10.00/1.00
�Vfi III L:IA)r 16117,r Ile/ LIc.No.7 ///Z LIGHTING FIXTURES 10.00/1.00
CONTRACTORS $cLi APPLIANCES-RESIDENTIAL 4.00
ADDRESS
lob at-, D PHONE -D / PANELS 10.00 DATE OF APPLICATION
ARCHITECT
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER C.NO. SIGNS TRANS. 3.00
ADDRESS ENc. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP rrEMP.METER OR POLE INS. 20.00
ADDRESr
Ns MOTORS SEE FEE SDH.
SERVICE CHANGE . „ 20.00
wo o LICENSED CONTRACTORS DECLARATION O ✓�'9' P` /U$r'Q/t-t-�� Cl 9/l0 If-7
a U,U 1 herebyaffirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
p n GaNi' S= 60
r a (commencing wish Section 7000)of Division 3 of the Business anJ BLD.. ELECT. PLG. MECH.
F i Professions Code,an
d7li license is in full for
x ❑ ❑
o IMn - License Cla Lie.Number ` _ r' Q ❑
o R ° Date/ Contractor�-L__��.QT-
Q y E j F I VI BUILDING PERMIT
rc tc w OWNhR-BUILDER DECLARATION IlOySdQ'"' r�"- INFORMATION
oA. MISC.- REFER TO ORD
w3 LL H I hereby elfin..that I am exempt from the Contractor's License VALUATION $/FT.
.. o< Law for the following reason (Site 703 1.5,Busincssand Professions PERMIT ISSUANCE 10.00 G �
EN J Code:Any city or county which requiresa permit toconstruct.alteq
re , Q 2O improve,demolish,or repair any mmclrr0.prior t0 its issuance,also ELEC.COPTS. LIC.NO. ELEC.
O LL requires the applicant for such permit u,file a signed statement that TOTAL 36 PERMIT TO
A w m he is licensed pursuant to the provisions of the Contractor's License
Rzas Law(Chapter 9(commencing with Section 7000)of Division 3 of the LEG
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ; $ by any applicant for a permit subjects the applicant to a civil pctiulty ALTER-DRAIN&VENT-WATER (EA.) 5.00
Pilot mom than live hundred dollars(8500).1:
❑ I,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 does not apply to an owner of
. property who builds of improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided That such improve-
motifs are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA..SYSTEM-OVER 4(EA.) 2.00 RUILDING USE
builder will have the burden of proving that he did not build or in* RES IND CON PR Omer
prove for purpose Of ,dr.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
❑ 1,as owner of the properly,am exclusively contracting with
licensed contractors to construct tiro project ISee. 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 as owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contractions)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACTNO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under S,C. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to sell'-insure. ZONING ENG.SITE NO.
or a certifeme of Workers'Compensation Insurance or a certified
copy thereof(Sec.3800,Lab.C.), :-1 /?,-I,P cy No. Company ll" 6'X �F�P'
Q y..-Cetlifrd ropy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z D Certified copy is filed f`vi ll the city 'aspeation division. MISC.- REFER TO ORD, Y ❑ N❑ Y ❑ N❑
O Applicant_�V-.`--X11-L{�
W CUR'I'IFICATIi OF EXEMPTION PROM WO KERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 c.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PAL
LG. v❑ N❑ Y [3N❑
d O (This section need not be completed if the permit is for one TOT
:D Z hundred dollars IS 100)or less.l
U O 1 certify that in the performance of the work for which this per STV. MECHANICAL PERMIT FEE FEE SUMMARY
, P mit is issued.I shall not employ any person in any manner so as To
Ow become subject W tile ns
e Workers Compeation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} W NOTICE TO APPLICANT: If,after nmking this Certificate of Ex-
Z 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
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 affirnn 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(See. MICROFILM
3097,Civ.C.). 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 36 O1 .
Lender's Address
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-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate 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 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 C' y in consequence of the PERMIT ISSUANCE 10.00
granting of this to . - MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
y
Signature of Applica t/Contractor D to
OFFICE COPY