12704 APPLICANT TO FILL IN.INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION I PERMIT NUMBER
BUILDING . t > APPLICATION & PERMIT
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
12704
OWNS
R' " PLAN CHECK VALIDATION
"AME (.` IN y ELECTRIC PERMIT FEE
vI o1rvE
CON FACTORS (1' OUTLETS-SWITCHES-RECEP 10.00/1.00
NA r
Llc. LIGHTING FIXTURES 10,00/1.00 ,
CONT TORS APPLIANCES-RESIDENTIAL 4.00
ADDR 1T ,^r�yx`� R •
�'�5N]6 , • V10 PANELS 10.00 DATE OF APPLICATION
ARCRI
OR ECT ; PANELS (OVER 200 AMP) .20.00 PLAN CHECK FEE PC.NO.
ENGINEER „ -
- - LIC.No. - SIGNS TRANS. 3.00
ADRCH OR DRESS E"G. SPECIAL CIRCUIT 5.00 - ' PERMIT VALIDATION _
1
ZIP EMP. METER OR POLE INS. 20.00
noxa SSTs IMOTORS SEE FEE SCH. //9 �'IN
SERVICE CHANGE 20.00
o IS LICENSED CONTRACTORS DECLARATION '
U U I hereby it that I am licensed under provisions of Chapter 9 ISSUANCE OATS
(commencing wllh Se [ion 7000)of Division 3 oPOne Business anA BLDG. ELECT. PLG. MECH.
r 'z' Professions C e,e - icense is in full f c
Z 0 m o
License Cppss Lis.Number ISL
F w H J Date__V r' IT
UU, ontrador IyCZY RM
I BUILDIRMATI N
¢ ¢ a OWNIi RB UI DIiR DECLARATIO
a o a u - INFORMATION
X ; u r Lhernby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD
LL a j Law for the following reason.(Sea 7031.5,Business and Professions VALUATION $/FT.
_ PERMIT ISSUANCE - 10.00
Code:Any city or county repair my ramit"IC permit o construct,,also
¢ ¢ ¢ , improve,demolish,or repair any permit
prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
al -O u requires the applicant for such permit to file a signed statement that f TOTAL PERMIT TO
`. w a he is licensed pursuant to line provisions of the
ri4 >o Contractor's License
Law(Chacowith Section 0) (Divsioofthe
Business and Profession,Code)or that he is cxcmpt therefrom - I �•Cpp:VU
and DTV. PLUMBING PERMIT FEE
¢ Ho' the basis for the alleged exemption.Any violation ofSedion7031.5 - I STORIES TYPE CONSTR;
a3 `3 by any applicant for a permit subjects the applicant to a civil penalty - ALTER-DRAIN (EA.)of not mom than five hundred dollars(5500).): - "
❑ I,as owner of the property,or my employees with wages as BACK,F LOW 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 50.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
1 merrtsam not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I1NC.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 im- BUILDING USE .
prove for purpose of,sde.). - INDUSTRIALWASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with I] ❑ El , ❑
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 an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 '
contracts for such projects with a contnetons)licensed pursuant to
- the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
reason
l am exempt under Sec. ;B.&P.C.fir this WATER HEATER W/VENT6.00 y
Owner Date WATER SYSTEM S,OO ACC.DATE .ACC.FILENO.
WORKERS'COMPI,NSAI'ION DECLARATION WATER TREATING EQUIP. .5.00
I hereby affirm that I have a certificate of consent to self-insure,
or lif¢at om pensal,onI sI anc•, r' certific ZONING ENG.SITE NO.
co i C.),
Poli
Cl CertiGL is here furnished! '
Z 2 ❑ Certified t is filtd with he 4'T s lionviz'o FIRE SPR INK ENERGY TY4
O Applicant + MISC.- REFER TO ORD. Y N o - Y ❑ NC]
~ a PERMIT ISSUANCE 10.00 c
� - CIi'L,on ATG F SAX ION FROM WORK F.RS' FLOOD ZONE A.L.U.C.
W O 'F.NSATION INSURANCE PLG.CONTR. , LIC.N0. PLG.
CL Cl (This section 'e not be Completed if the permit'is for one TOTAL Y❑ N 0 Y❑ NJ
M Z hundred dollars(b )or Icss.)
L) O I artily that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
W U mit is issued, I shall not employ any person in any manner sr as to
become subject to the Workers'Compensation Laws of California.
GO Date Applicant BUILDING
} to NOTICE. TO APPLICANT: If,after making this Certificate of fix- - ALTER OR ADD TO MECH. 5.00
F 2 emption,you should become subject to tiro Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of tine Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be decried revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.EM.) 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(See. MICROFILM
3097,Civ.C.L - t HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name - HEATING UN IT B.T.U.)9.50 ,
Lender's 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-
ordinances and state laws relating to building construction, and BOILER-OOMP(3H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL"
(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
ay in any y accrue'agsind,said City in con�e1llLence of the PERMIT ISSUANCE 10.00
g run Of hi. ermlt. \ MECH.CONT. LIC.NO, MECH.
r 1 TOTAL TOTAL �E
ig azure Applicant/Contractor Date
OFFICECOPY - ..It