12756 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFIC N PERMIT NUMBER
BUILDING APPLICATION & P IT
AOORE56
BUILDING-ELECTRICAL-PLUMBING-'MECHANICAL 12756
OWNER'S PLAN CHECK VALIDATION
NAM
"AME`', QTY. ELECTRIC PERMIT FEE
W m - PHONE
CONTRACTORS
N M myI1/ 1 ``..�� UTLETS-SWITCHES-RECEP 10.0011.00
M / /u1J �
.No. /y- LIGHTING FIXTURES 10.00/1.00
CONTRACTORSPPLIANCES-RESIDENTIAL 4.00
ADDREss V 11,,`j µ PHONE(JA77 �- PANELS 10,00 DATE OF APPLICATION
/ ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
Ofl
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERI.�VALIOATION
ADDRESS SPECIAL CIRCUIT 5.00 O
ZIP EMP.METER OR POLE INS. 20.00 �D
ADDRESS MOTORS SEE FEE SCH. JAN (�
ADDRESS O3198
' SERVICE CHANGE 20.00
w O o LICENSED CONTRACTORS DECLARATIONc- ofaa v v hereby aftrrm that I am licensed under provisions of Chapter 9 I AN
(cli in nein with Section 7000)of Division 3 of the Business and
BLDG. ELECT, PN3.111 MECH.
Pro essions Co my license is in full for ada ec. El 11 ❑
io= Li nae Cl s Lie.Number
o_ H D le / Contractor
a x f BUILDING PE MIT
¢ ¢ a OWNER-BUILDER DECLARATION
¢ w v INFORMAT ON
'x;LL H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
w u O a Law for the following reason.(Sec.7031.5,Bcsinessend Professions VALUATION E/FT.
� - Code:Anycilyorcounty which requires a permit to construct,ulteq PERMIT ISSUANCE 10.00
2 aa¢FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a a c ¢ requires the applicant for such permit to file a signed statement that TOTAL P RMI
ac m he is licensed pursuant to the provisions of the Contractor's License
Hz > Law(Chapter 9(Commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
2 f g the basis for the alleged exemption.Any violation of Section 7031.5 TO 5 VPE BTR.
n3 - byany applicant fora permit Subjects the applicant tea 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 RE NITS
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. 5.0
Code:The Contractor's License Law does not apply to an owner of
�I, property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.0 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-1 6.00
meals are not intended or offered for sale.If,however,the building
or Improvement is old within one yew of completion,the owne .
builder will have the burden of proving that he did not build or imr GAS-EA.SYSTEM-OVER 4(EA.) 2 00 BUILDING ugE- RES IND CON PS Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,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 properly who builds or improves thereon,and who LAWN SPO INKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contracror(s)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sea. ,B.&P.C. rthis WATER HEATER WIVENT 6.00
reason
Owner Date WATER SYSTEM - 5.00
ACC.DATE ACL.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-lnsnre, ZONING ENG.SITE NO.
or a certificate thereof
of Workers'Compensal1�nAr154�jr{,g��i lificd
copy -17(rl C,{"L�W61
Policy Na. Company -
O ❑ Certified copy is hgl�
F:Rby furnished.° FIR E SPR INK ENERGY T34
Z ZO 1b Certified cry islAaei{hstke�city inspection division. MISC- REFERTOORD, yY [3 NE] Y❑ NN[]qh ..cant 66A.1-E:.j
Hy R�7J PERMIT ISSUANCE 10.00 PLOOOZONE A.L.U.C.
LU - CTI CERTIFICATE EXEMPTION FROM WORKERS'
CL 0 COM not be ora INSURANCE PLG.CONTR. LIC.NO. TLOT,A Y❑ N❑ Y ❑ N❑
D Z hundred
section need not he completed if the permit is for one
hundred fy that(in th)performance
LL O I certify that h the performance of else work for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner So as to
U become subject to the Workers'Compensation laws of California.
O Uu Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
> N NOTICE TO APPLICANT: If,after making this Certificate of Ex.
F ? 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
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 10P00C.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 dor which this permit is issued(Sec.
3097, HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
s Na).
Leader's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and ,are 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-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
abuvc�menlioned 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 an way acerae against said City in consequence of the PERMIT ISSUANCE 10.00
gnmB of is rmit �T MECH.CONT. LIC.NO. MECH.
cI /-r�549 TOTAL TOTAL n
Signature oTApplicant/Contractor Date v
OFFICE COPY