12477 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFIC4WN PERMITNUMBER
BDILDING APPLICATION & P IT
X.
'17P 57 Bubb fW BUILDING-ELECTRICAL-PLUMBING-MECHANICAL: 12477
OWNER'S PLAN CHECK VALIDATION
NAM• CON
W.N. �f Q�• ELECTRIC PERMIT FEE
W. DA PHONEa7�• 896
NA.ERACTOR'S A^ 100 UTLETS-SWITCHES-RECEP 10.00/1.00
• LIC.NO. 'E-`�•-/ LIGHTING FIXTURES 10.00/1.00
-{� ADDRESSTDRS 1 LOlS8 PPLIANCES-RESIDENTIAL 4.00
�0al CAGW O Cif CAd PHONE3511s. 3416 PANELS 10.00 D� DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 2n pin PLAN CHELK FEE P.C.NO.
OR
ENGINEER Q Assoc,fifiG(•
gJ,. ('g rY na4{m�.rvyo.�y' SIGNS TRANS. . 3.00
ARCH.OR ENG. •• ftJ� 1 / SPECIALCIRCUIT C . 5.00 PERMI VAL11DATION
ADDRESS e AID
17509�q WR ziPiSi*I TEMP.METER OR POLE INS. 20.00
APPLICANTS- MOTORS SEE FEE SCH. MAR
y ��
ADORE S �,� _ I /
X2940 W�Wa I•E•�L1) SERVICE CHANGE 20.00 pp� ` pp
0 0 0 LICENSED CONTRACTORS DECLARATION City oL yQ00Q
C u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
vFi<H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F Professions CoJ _fid/ryy license is in full fo f`e3tZ ❑ ❑ ❑
z o w Licenu Clns N Lic.Number _r..�
g F w Dete ContractorC Id •�LM
a y EiL OeMI'. BUILDING PERMIT
Ix w 4 OWNER-BUILDER DECLARATION INFORMATION
D REFER TO ORD
X ; u N I hereby affirm that I am exempt from the Contractor's License MISC.- VALUATION $/FT.
u04 Law for the following mason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
E mCode:Any city or county which requires permit to construct,alter,
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO ELEC. (/V
d 0 Ow requires Ile applicant for Such permit to Ole a signed Sbilemenl that TOTAL PERMIT TO
ww he is licensed pursuant to the provisions of the Contractor's License
Fir Law(Chapmr 9(commencing will Section 7000)ofDivision3oflhe �1 7
4 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
Ic the basis for the alleged exemption.Any violation of5eelion7031.5 STORIES TYPE CONSTR.
a by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not mom than five hundred dollars(%500).):
❑ 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 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
cuts are not intended or offered for sale.if,however,the budding GAS-EA.SVSTEM-1 6.00
m
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- R IND .CON PS CO.,
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 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 conHactons)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ tum exempt under Sec. ,B.&P.C.1'or oris 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
I hereby affirm that I have a certificate of consent to sell'-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
-2,, copy theeyLab.C.l
Policy N � jCompany
AIWA -Two.
Q ❑ Certified copy is hereby furnished.
FIRE%PRINK ENERGY T-24
Z_ zi, ❑ Certi ' �o rs leJ�wit the cYy inspection division. MISC. REFER TO ORD. y ❑ N❑ y ❑ N❑
O Applicant- IMRL�(AI
ccPERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
� - CERTIFICATEOFEXEMPTION FROM WORKERS'
a Q COMPENSATION be completed
INSURANCE PLG.CONTR. LIC.NO. TOTAL Y❑ N❑ Y ❑ N❑
� Z (This dollars need not be completed if Lite permit is for one
hundred dollars IS 1the pe less.)
LL O I certify that h the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P0L) mit is issued,e 1 shall not employ any person in any manneror is Io
U become subject to the Workers'Compensation Laws of California. BUILDING
Lal Date ApplicantALTER OR ADD TO MECH. 5.00
} N NOTICE.TO APPLICANT: If,after making this Certificate of Ex-
I.. Z 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
CJ Such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,00DCF.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,CN.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(O
Lender's Address VER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
\ information is correct}agree to comply with all city and county PLUMBING
J ordinances and state laws relating to building construction, and BOILER•CONW(3 H.P.or 100,0000.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IOverlOO,000BTU)SEEFEESCH. 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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue,against mid City in consequence of the
granhngo this emit. MECH.CONT. LIC.NO. MECH.
\ g Ci/ vt s�i4�gJ TOTAL TOTAL
xSignature of Applicant/Contractor Dal
OFFICE COPY