13459 APPLICANT TO FILL IN INF(I"MATION WITHIN RED LINES - USE RnLL POINT PEN ONLY
BUILDING PROJECT IDENTIFICA. JN PERMIT NUMBER
BUILDING APPLICATION & PEhrv1IT 13459
ADDRESS BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
W
TINNED - '_.- - PLAN CHECK VALIDATION
ME I
�-,^; 'ELECTRIC PERMIT 1., ,�'.
• PHON sKNoMER" °Rs UTLETS-SWITCHES-RECEP 10.00/100 IOuC.No. IGHTING FIXTURES 10.00/1.00CONTRACTOR S 1aSO Qt�,e'•-cPPLIANCES-RESIDENTIAL 4.00
A FESS
PHONE _ PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLA"CHECK PEE v.c.NO,
OR
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ARCS.OR ENG. SPECIAL CIRCUIT S,OD PE MIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00 -
APPLICANT sMOTORS SEE FEE SCH. (��1�
AODREAS
SERVICE CHANGE 20.00 /
/i0 /r7
wac O LICENSED CONTRACTORS DECLARATIO.
a u u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
I
, i (commencing with Section 7000)of Division 3 of the Business and .BLDG. E ECT. PLG. MECH.
H w i Professions Code rid y license o ra full force and a t.
0 w License a Lic.Number ❑ - ❑ ❑
I m r w Dale - CoNractor
QBUILDINGIP.ERMIT p
w u OWNER-BUILDER DECLARATION „.1IN FORMATION Y 1 w'Y
u w I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD S
w0 ec Law for the following reason.(Sec.703 1.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
- - 0 Code:Any cityorcounty which requires a permit to construct.alter,
< p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
requires the applicant for such permit to file a signed statement that TOTAL -ov PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License ..a:
t Law(Chapter 9(commencing with Section 7000)of Division 3 of the 2a ;; " $++,,.r'' aT"�> [6'z.L m ♦'"c. Y S
a Business and Professions Code)or that he is exempt therefrom and CITY:w: x 'PLUMBING PERMIT 1'` 1 >r'. FEE;.;
o the basis for the alleged exemption.Any violation of5ection 7031 5 ,k:i.'M;n. r ka..`.^:h'li. 4 Y ,sut M�.,3'«.�trt 'v ^eT^t.:T STORIES TYPE CONSTR. '
i ; m by any applicant for.perrnitsubjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the swcture rs not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,GOND. 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 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
merits are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-i INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA) 200 BUILDING USE
builder will have the burden of proving that he did not build or im- . . .
RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,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 Contractors 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 contractogs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law. - I
❑ I am exempt under Sec.-,B.&P.C.for this 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 1 have a certificate of consent to sel Gin sure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
�y Copy thereof(Sec.3800,Lab.C.).
$` Policy No. Company F
O ❑ fRrtified copy'is hereby furnished. I FIRE SPRINK ENERGY T 24
Z Z Ce,iO d coy s A i e uty inspersion Jivison.
O Applicant `�_ ' .C��i r-, MISC.- REFER TO ORD. Y ❑ -Ell Y ED N❑
DC w CERTIFICATE OP EXEMPTION 17ROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.u.C.
Lu 7_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. I V N❑ Y 1:1 N
CL O (This section need not be completed if the permit is for one TOTAL
Z hundred dollars(S100)or less.) - '
U O I certify that In the performance of the work for which this p r QTY.'. MECHANICAL PERMIT' FEE FEE SUMMARY
LL H mit is issued.I shall not employ any person in any manner so us to v' y •1
U become subject to the Workers'Compensation Laws of California. - BUILDING
U i Dam Applicant ALTER OR ADD TO MECH 5.00
>_ to NOTICE TO APPLICANT: If.after making this Cer I tate of Ex-
Z_ emption,you should become subject to the Workers'Compcn ation App LI ANCE 5.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1OJ300 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. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's dameHEATING UNIT(0 VER 100,000 B.T.U.)9.50 ELECTRIC /
Lenders Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county I PLUMBING
ordinances and state laws relating to building construction. and BOILER-COMP13 H.P.Or 100,000 B.T.U.1 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. I MECHANICAL
above-mentioned properly 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 PERMIT ISSUANCE 10.00 I CONST.TAX
an Y, any way acerae opoi pt Said Cil, in conse"c of the
grantrn//of IS pergyiL MECH.CONT. LIC.NO. MECH.
/ V, C TOTAL TOTAL
ignal of Applicant/Contractor D e
05'&-617t/oS Cl't