12852 APPLICANT TO FILL IN INF RMATION WITHIN RED LINES - USE ALL POINT PEN ONLY
BU LDING PROJECT 1 DENTI F ION APPLICATION & P MIT PERMIT NUMBER
anLO SS
�J
So
/O
/s o GD _qR OR VE BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12852
OWNER'S PLAN CHECK VALIDATION
•7` "AME QTV / ELECTRIC PERMIT FEE
PRDNE 6
/ CO TRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
7'\ NAE
1V LIC NO. LIGHTING FIXTURES 10.00/1.00 10
CONTRACTOR'S S/GN 7t/SE 9s(/J3 PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PO. PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ADDRESS"S E"O' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS FEE SCH.
ADDRESS 7
SERVICE CHANGE 0.00 �a'�/�/
w o O LICENSED CONTRACTORS DECLARATION r
<v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
G a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H D'^ Professions Code,and y license is in full fort an effect_�/ ❑ ❑ ❑
z O'=-- icense Class Lic.Number
z w Dale Contractor gIYIJ
a x s .�. BUILDING PERMIT
a m w OWNER-BUILDER DECLARATION INFORMATION
w0 a I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
3 ,4 VALUATION $/FT.
FLL0 < Law for the following reason.(Sec.7031.5.Business Professions PERMIT ISSUANCE 10.00 Q �
w Code:Any city or county which requiresa permit toconstracL alter,
Ii ¢FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. TI/
O Ie requires the applicant for such permit to file a signed statement that �1Q(-I TOTAL / y� PERMIT TO
w$a- he is licensed pursuant to the provisions of the Contractor's License
FiQ Law(Chapter 9(commencing with Section 7000)of Division 3 of the ,
3 i O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
It I- the basis for the alleged exemption.Any violation of Section 703 LS STORIES TYPE CONSTR.
w. by any applicant for a permit subjects the applicant los civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
(heir sole compensation,will do the work,and the structure is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
• property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5,00 F. FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SV STEM-11NC.40UTLET$ 8.00
ments are not intended or offered for sale.If,however,the building
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- E IND CON PB Omer
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 property who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forh projects with a contraetorls)licensed pursuant to
the Contractor'sactor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec..,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION D17CLARATION WATER TREATING EQUIP. 5.00
I hereby efOrm that 1 have a certificate of consent to self-insure,
or a Certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
_C 1 copy thereof(Sec.3800,LAC,).
l_ Policy No. Company
O ❑ Certified copy is hereby furnished. I FIRE SPRINK ENERGY T-24
Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
Applicant - Y ❑ N❑ Y ❑ No
K y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
111 > COMPENSATION INSURANCE PLG.CONTE. LID.NO. PLG,
1 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ No
:) Z hundreddollars(SID()orlem.)
U O I certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U becom�syb�'ec�{�the Workers-'C��o�IP�pensa-li1oI�.:��w�s o�f C�alifor-nia.
O y Dateeltq/!.^_.r.1-Applicant I g 0 ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,a ler ma mg this C tificale of Ex-
H Z emp(ion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you mus( 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 IODWC.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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and stale 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(3H.P.or 100,000B.T.U.) 6.00
' hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. 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 said City in consequence of the
s` granting of this pelmit. MECH.CONL LIC.NO. MECH.
_G TOTAL TOTAL
Si ature ofA lica Contra c Date C
OFFICE COPY