12792 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.- USE BALL POINT PEN'ONLY
BU I LDING PROJECT I DENT[FICATION PER MIT NUMBER
UILDIN
ADDRESS
�! - . APPLICATION & PERMIT 12792�� ��
aS.�O C�fT�/,1J.Lx �f,r BUILDING — ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S _ PLAN CHECK VALIDATION
•� NA ,`/.'' 7_fl -Si�I-J CITY. ELECTRIC PERMIT FEE,
PHONE
CONTRACTOR'S
NAME _ UTLETS-SWITCHES-RECEP 10.00/1.00.
LIC.No, LIGHTING FIXTURES 10.00/1.00
ADDDREssro R's - APPLIANCES-RESIDENTIAL 4.00 '
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO..
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC NO. SIGNS TRANS. •3.00
ADDRESS ENc. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICECHANGE 20.00
O 0 LICENSED CONTRACTORS DECLARATION vii/°�—/g �
o ¢ i .
r
¢ U u I hereby affirm that 1 am licensed under provisions of Chapter 9
in z w ISSUANCE DATE
a (commencing with Section 7000)of Division 3 of the Business and
OLOG. -ELECT. PLG. MECH.
H D i Professions Code,and my license is In full forec and effect. - - ❑ ❑ ❑
9 z w p License Class Con Number
w b.w Date Contractor
Q M E
¢ ¢ a OWNER-BUILDER DECLARATION BUILDING PERMIT
w— o i U INFORMATION
; N 1 hereby affirm that I am exempt from the Contractor's License 'MISC.— REFER TO ORD
w o st Law for the following reason.(Sec.7031.5,Business and Professions VALUATION
r — PERMIT ISSUANCE 10.00
I w�+ � Code:Any city or county which requires permit to construct,alter, - -
¢ ¢ Q O Improve,demolish,of repair any structure,prior to its issuance;also ELEC.CONTR. LIC.N0. ELEC.
m LL requires the applicant for such permit to file a signed statement that TOTAL
K
ow w he is licensed pursuant to the provisions of the Contractor's License P PERMIT
H > Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe 'it
tr-
i o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
M I- r� the basis for the alleged exemption.Any violation of Section7031.5 STORIES TYPE CONSTR.
by any applicant fora permit subjectsthe licam toacivil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).1:
❑ L as owner of the property,or my my ememployees with wages as BACK FLOW PROTECT. DEVICE 400
their sole compensation,will do the work,and the structure is not OCL.GROUP RES.UNITS'
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
. property who funds a,improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im. GAS-EA.SYSTEM-OVER 4( 2,00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. S0 RES IND CON PB Oma,
❑ 1,as owner of the properly,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 '
and Professions Code:The Contractor's License Law does not apply ASSESSORS PARCEL NO.
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS'-OV A.) 1.00
contracts for such projects with a contractoms)licensed pursuant to
the Contractor's License Law. - SEWER-SANITARY-STORME O TRACT NO, PARCEL NO.
❑ I am ex t t on es e BAP.C.for this
reason ; '"1_� �3 WATER HEATER W/VENT• 6.00
Owner / _-WATER.SYSTEM 5.00 ACC.DATE ACO.FILE N0.
WORKERS'COMPENSATION DECLARATION 5.00 -
♦ hereby affirm that 1 have a certificate of consent to self insure, - '/
or a certificate of Workers'Compensation Insurance,or a cL tified /'`'�` ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJ.
Policy No.' Company
Q ❑ Certified copy is hereby furnished. FIRE$PRINK ENERGY T24
Z Z ❑ Certified copy is riled with the city inspection division.
F 0 Applicant IMISC.- REFER TO ORD. Y N❑ Y E] N�
N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.LU.c.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. ALO.
d O (This section need not be completed if the permit is for one TOTAL / V N� 'Y❑ NEI
Z hundred dollars IS 100)or less.) `_
El
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If;after making this Certificate of Ex.
Z emption,you should become subject to the Workers'Compensation APPLIANCE
I_ 5.00 PLAN CHECK
provisions io the Labor Code, you must d evoked.comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10/100C.F.MJ- 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 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,Civ.cJ. a HEATING UNIT(TO 100,000 B.T.U.) B-00
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information-is correct. 1 agree to comply with all city and county PLUMBING �_zI`_p
�. ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.Or 100,000 B.T.U.1 6.00 /e"0
hereby authorize this representatives othis city to enter upon the
above-mentioned property for representatives
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 PERMIT ISSUANCE ORD. CONST.TAX
in "
may way accan st said City in consequence of the
grand t a p omit. n r r MECH.CONT. LIC.NO. MECH.
11 (.E�✓^1.¢U• TOTAL TOTAL
ignatui of Applicant Contractor Dale
- - OFFICE COPY -