12695 (2) I - ,
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LOI NG PROJECT I DENTI FICATION PERMIT NUMBER
BUIL NU ,. APPLICATION & PERMIT
ADOREss
VV /Q� �CJl9t-IC o BUILDING -ELECTRICAL-PLUMBING-MECHANICAL12695
OWNER'S, �S5 - PLAN CHECK VALIDATION
S t `� DTV. ELECTRIC PERMIT FEE
N ME
7 PHONE
CONTRACTOR'S OUTLETS-SWITCHES•RECEP 10.00/1.00 50
N ME S0z9�5e
e lL No, LIGHTING FIXTURES 10.00/1.00
r,ONTRACTORS Z PPLIANCES-RESIDENTIAL 4.00
ADDRESS#0047 se,NIG
N PHONE PANELS 110.00 DATE OF APPLICATION'
ARCHITECT PANELS (OVER 200 AMP) 20.0 PLAN CHECK FEE P:L.NO.
OR
ENGINEER "
UC.NO, SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 - PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 ^
ASMOTORS SEE FEE SCH.
ADDDREDRESSS
SERVICE CHANMMD 20.00
w �`Q
M,i u herebyaffirm that I am licensed under provisions of Chapter 9
09 LICENSED CONTRACTORS DFrCLARATION
a n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLgi.� MECH.
F w i Professions Code nd my license is in full f e ej(efl��
z a w- License Class- Lia Number `7_�_.Z_ v I[\ N�; 1
- Date Contractor. ``;ty OE CU4e
" w f <� BUILDING P T
w < OWNER-BUILDER t from ( TION •S E(Aiii 'I
X 3 n 1- I hereby affirm That I am exempt from the Contractor's License
MISC.- REFER TO ORD
1_0¢ Law forthe followingreason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
NJ Code:Anycity orcounly which requires a permit to construct,alter, D Qa
ac a Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIQ NO. ELEC. /•s r� /73/L
It requires the applicant for such permit to file a signed statement that TOTAL (DLV PERMIT TO
wr$a he is licensed pursuant to the provisions of the Contractor's License (� w /
rzr Law.(Chapter 9(commencing with Section 7000)of Division 3 of the J L�
a: Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
ce the bbsis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE ACONSTR.
by any applicant fora permit subjects(h5000.)applicant civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than flea hundred dollars the appl:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 Oce.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
T property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 Q SO.FT.FLOOR AREA TOTAL ACREAGE 1
himself re through his own employees.Provided that such improve- . p
hients mself c through
intendeughhis or emered forployees.
a.provided
that s [lie building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 K7�
or improvement is sold within one your of completion,the owner. GAS-EA.SV STEM-OVER 4 (EA.) - "2.00 BUILDING USE builder will have the burden of proving(hat he did not build qr im- RES IND CON PB Other
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 •) _ �(iQ c//
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 K U v T
contracts for such projects with a Nconiractor(sI licensed pursuant to SEWER-SANIRM .200ft/10.00
the Contractor's EA
s License Law. ,Q TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.lot this WATER HEATTAR WO NT 6.00
reason
Owner Date WATERSYSTEMA Y (� 1 5.00 ,S''- ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATERT A'f•IN 'EQUIP. 5.00 -
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compen union Insurance,or a certified -
copy(hereof(Sec.3800;hab.CJ.
Policy Na. Company
❑ ,C ed copy is hereby famished. FIRE SPRINK ENERGY T-24
❑I' er IO �COMPENSATION
' iins tion d' Ian.4� MISC.- REFER TOORD. Y❑ N❑ Y ❑ N❑TIM WORKERS' PERMIT ISSUANCE 10.00 QFLOGO ZONE A.L.U.C.
LU - NCE PLG.CONTR. LIC.NO. PLO,
CL o (This section need not be completed if the permit is for one TOTAL / Y❑ N❑ Y❑ N❑
=) 2 hundred dollars(S 100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECH [ PERMIT FEE FEE SUMMARY
Q I- mit is issued,I shall not employ any person in any manner so as to
r ���-
O W become subject to the Workers'Compensation Laws of California'
Date Applicant - ALTER OR AD H 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
�.. ? - 'emption,you should become subject to the Workers'Compensation APPLIANC 1 T ME 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 T 1 .M.1 4.00
CONSTRUCTION LENDING AGENCY, AIR HANDLIN 6X0 C-F.M.I 6.00 SEISMIC FEE / y
I hereby affirm that (here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address - - -
a1 I rime I. Thal I have read this application and slide that the above VENTILATION FAN MINGLE) 4.00
information correct.I agree to comply with all city and county PLUMBING Q -
+� oNilianas and state laws relating to building construction, and B6ILER-eoMP(3 H.P.or 100,000 B.T.U.) 6.00
%hereby-authorize representatives of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL i
p above-mentioned property for inspection purposes.
1\\ (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 Q I CONST.TAX -7,�
in any way accrue Against said ity 'n consequence of the
gran of this per L MECH.CONT. LIC.NO.. MECH.
iiiZ .l6 TOTAL a7 `r TOTALk6j
gnmureof Applicant/Cantr� le
OFFICECOPV