12117 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 1 Clix-�� �n✓ski G-ELECTRICAL-PLUMBING -MECHANICAL 12117 .
OWNINAMERS 0.)xet - Q�-/,OSI PLAN CHECK VALIDATION
'Md-C_O Fr/. / ( I
QTY.
ELECTRIC PERMIT FEE
I PHONE
crDRs
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
I- - LIC.No. LIGHTING FIXTURES 10.00/1.00
ADoR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00 a
ENGINEER
uc.No. ISIGNS TRANS. 3.00
As H.OR ENO. r ,PERMIT VALIDATION
.-
ADDRESS SPECIAL CIRCUIT 5.00 s1 J s I -
ZIP EMP.METER OR POLE INS. 20.00 ,1
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
�a
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION
a v t 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w a m (commencing with Section 7000)of Division 3 of the Business and -y B ELECT. PLG. MECH.
H D w Professions Code,and my license is in full force and effect. - G -
= ❑ ❑ O
o i License Class • Lic.Number
H mH J Date Contractor�
a m s °.
¢ ¢ a OWNER-BUILDER DECLARATION
a a u BUILDING PERMIT,
,
w u.r 1 hereby affirm that 1 am exempt from the Contractor's License. MISC.- REFER TO ORD ( 'INFORMATION r
r
HUOJ Law for the followingmason.(Sec.7031,5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
„rsa Code:Any city or cou n ty which req vires a perm it to construct,alter,
Be w ¢ p improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
OIL
m
U. he is licensed pursuant m the provisions of the Contractor's License
FiQ
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe "' r
S 4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H$ the basis for the alleged exemption.Any violation of Section 7031.5 . STORIES VPE CONSTR.
w. by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,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 or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SM FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
, 'mems are not intended or offered for sale.ll',however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or in,. BUILDING USE
P
T
far purpose its""
INDUSTRIAL WASTE INTER. 30.00 IND CON PB other
I,as owner o1'the property,am exclusively contracting with _ ❑ ❑ ❑ ❑
ed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
rofessions Code:The Contractor's License Luw does not apply ownar of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 '
contracts for such projects with a contractods)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
O I am exempt under S6,-,BAP.C.for this WATER HEATER W/VENT 6.00
Wier Date 4 WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DEC.A RATION WATER TREATING EQUIP. 5.00 '
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
'copy thercof(Sec.3800,Lab.CJ.
Policy No. 'Company '
r O Certified<Opy is hereby furnished. FIRE SPRINK ENERGY T�24
Z 2 ❑ Certified copy is.filed with the city inspection division. MISC.- REFER TO ORD.
Q Applicant V ❑ N❑ y ❑ N❑
~ va PERMIT ISSUANCE 10.00
� - CIiRTIFICCOMOFSATIOTINS FROM WORKERS' FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.coNrR. LIC.NO. PLG.
(L aZ ('Phis section need not he completed if the permit is for one TOTAL Y❑ N❑ V❑ N❑
hundred dollars IS 100)or less I
V O I certify that in the performance of the work for which this per- QTY. / MECHANICAL PERMIT FEE FEE SUMMARY
1L 1- mil is issued, I shall not employ any person in any manner so as to
O W rs become subject to the WorkeCompensation Laws of California,
a Date-Applicant BUILDI
ALTER OR ADD TO MECH. 5.00 NG !.✓/
} w NOTICE '1'0 APPLICANT: If,after making this Certificate of Ex-
F Z emplion,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 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOPWC.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,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lenders Address ELECTRIC
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 - PLUMBING
or and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP 1 er t ,0 TUI SE�FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- EFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way-accrue,against said City in consequence of the
grant)ng of this perp MECH.CONT. LIC.N0. MECH,
_x604/_ �l-T/ TOTAL TOTAL �J
Signature of Applicant/Contractor / Dafe
OFFICE COPY'