12346 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI ION PER NUMBER
♦��
.....ING APPLICATION & MIT 12346
ADDRESS
s�i CU BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OW NEfl'$
PLAN CHECK V IOPTION
.0/ �/yW. NAME //�/,�rrpp// QTY. ELECTRIC PERMIT FEE 9i
cONTRACTORS • L{�S�
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
W4/ LIGHTING FIXTURES
ae/f r
a-
10.00/1.00 '
nooeese S ,1_ APPLIANCES-RESIDENTIAL 4.00
q A � oPHONE� PANELS 10.00 DATE OF APPLICATION
Ogcurtecr PANELS (OVER-200 AMP). 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. ECIAL CIRCUIT 5.00
SPPERMIT VALIDATION
ADDRESS
- zip EMP.METER OR POLE INS. 20.00
APPLICANTS SEE FEE SCH.
MOTORS
ADDRESS
"--- ^^
= SERVICE CHANGE 20,00 ��/-G.v`-� .
w¢ PAID
H O O LICENSED CONTRACTORS DECLARATION -
1 hereby affirm that I am licensed under provisions of Chapter 9 [a
y a (commencing with-Section 7000)of Division 3 of the Business and ISSUANCE aTE/.
r O i Professions Code, my license is in full force and effect. L G. PLG: MECH.
z710 i=o License lass '" Lie.Number
m r w Date - t �7 Contractor S� S ❑ ❑
¢IS u OWNER- BUILDER DECLARATION kiSd rX l G PERMIT
K
I,u a I hereby affirm that I am exempt from the Contractor's License 'MISC.- - REFER TO ORD ''I"r"�^MATION
u O¢ Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
L- aa PERMIT ISSUANCE 10.00
f 'A�2 Cade:Any city or countyrepair which structure,
requires une,prior
o its is construct,alter,
IS a 4 O improve,demolish,or repair any structum,prior to its issuance,also ELEC.CONTR, - LIC.NO.
i w m u requires the applicant for such permit to file a signed statement that TOTAL l
he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
HiQ Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
f i O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE J 2csG-V
IS 1-o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n;m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN (EA.)of not more than five hundred dollars(5500).): -
❑ 1,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 property,
the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONO. 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 F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale,If,however,the building GAS-EA.SYSTEM-11NC.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 1,aso neeose of sale.). INDUSTRIAL WASTE INTER. 30.00 R IND .C❑oN O Other
❑ L as owner of the property,he exclusively contracting with,
licensed contractors: construct the project(Sea does,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does,at apply
to tr owner of property who builds t, improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such piojects with a contractor(s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO. PARCEL.NO.
❑ lam exempt under Sec..,BAP.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy Nyj d C' eito a#;O CAr("I"Ty
O ❑ Cue S eby furnished.
Z Z Certified C t x ed with th City in Ction division. r FIRE SPRINK ENERGY T-24
F O A licant MISC.- REFER TO ORD. Y❑ No Y ❑ N[]
� LO CERTIFICATE OFIXEM'IWNFRO WORKERS' PERMIT ISSUANCE , 10.00 FLOOD ZONE A.L.U.c. _
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. 1
CL Cl (This section need not be completed if the permit is for one TOTAL Y❑ N Y NED
Z hundred dollars IS 100)or lees.) -
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
y Date Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING r/d�
>- So NOTICE TO APPLICANT: If,after making this Certificate oft I-
F. Z emotion,you should become subject to the Workers'Compensation App LN
I ACE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with C.1 FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF,M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.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(Sec. MICROFILM
3097,Civ.C.). I HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
` Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 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-ODMP(3 H.P.or 100,000 B.T.U.) 6,00
hereby I authorize representatives this City to enter upon the BOILER-COMP (Over 100,000 BTU)SEE F EE SCH. MECHANICAL above-mentioned property for inspection purposes.
(We),agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino ago' 'abilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in a way/ac e a ainst said City in consequence of the '
grantin a MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL 9 O G
S' ' Applicant/C9 Date
OFFICE COPY