12823 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
BUILDING 12823
^ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
WNER's
\5 NA [f QTY. ELECTRIC PERMIT FEE
N PHONE
CONT ACTOR'S UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
IO.00 DATE K FEE P.L.NO.
APPLICATION
PHONE PANELS PLAN CHECK
ARCHITECT PANELS (OVER 200 AMP)
20.00
OR
LIC.NO. SIGNS TRANS. 3.00
5.00 P T VALIDATION
ARCH OR ENG. SPECIAL CIRCUIT
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00 �rp
APPLICANTS MOTORS SEE FEE SCH. tD
ADDRESS gy, �p1
SERVICE CHANGE -20.00 gs;g.E di WY'-
'02 LICENSED CONTRACTORS DECLARATION Val?
a:U u I hereby affirm that I am licensed under provisions of Chaplet 9 ISSUANDE DATE
N3 y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. M
r o i Professions Code,and my license is in full force and effect
z o. License Class Lic.Number
-
a N F w Date Contractor BUILDING PERMI
4 y E
a OWNER-BUILDER DECLARATION REFER TO ORD INFORMATION
o n xar MISC.-
w; r I hereby affirm that 1 am exempt from the Contractor's License VALUATION $/FT.
..o Law for the following reason(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
Q G improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- DLL requires the applicant for such permit to file a signed statement that TOTAL PE IT TO
w$ he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)ofDivisi°n3ofthe PLUMBING PERMIT FEE
< tlusmess and Professions Code)or that he is exempt therefrom and QTY. STORI S TYPE CONSTR.
H o the basis for the alleged exemption.Any violation of Section 7031.5 -
w. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five Imndred dollars(8500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4,00 OCCG
UP 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 5,00 a0.FT.FLOOR AREA TOTAL ACREAGE
Properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP
himself or through his own employees,provided that Such improve- GAS.EA.SYSTEM-11NC.40UTLETS 6.00
t ments are not intended or offered for sale.IL however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or ins- ^IND CON PB GO.,
ve for purpose of sale) INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
p0{$l$��y 1,as owner of the property,am exclusively contracting with
IisL•lked contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
-----
d
Professions Code:The Contractor's License Law does not apply -'
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.0 _-
--
contractsforsuchprojectswithaconlractnrls)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's me,Law.
exam on Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
rca Dal WATER SYSTEM 5.00
ACC.DATE ACG FILE NO.
Owne
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 '
I hereby affirm that 1 hove a certificate ofumsent to sell'-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lab.CJ.
Policy No. Company FIRE SPRINK ENERGY T-24
Q ❑ Certified copy is hereby furnished.
Z Z •❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. Y❑ N❑ v ❑ N❑
Applicant
)-- y PERMIT ISSUANCE 10.00 FLOOD ZONE
Cr - CERTIFICATE EXEMPTION FROM WORKERS' Y❑ N❑ v❑ N❑
W > , COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
TOTAL
Q. o (This section need not be completed if the permit is for one
=) Z hundred dollars($100)or less I FEE FEE SUMMARY
U O I certify that is the performance of the work for which this per OTY. MECHANICAL PERMIT
F mit is issued,I shall not employ any person in any manner so as to
LL O O become subject to the Workers'Compensmion Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} tai! NOTICE TO APPLICANT: If,after making this Certificate of F. 5.00 - PLAN CHECK
Z emporia,you should become subject to the Workers'Compensation APPLIANCE FEE
provisions of the Labor Code, you most forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10P00C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT IOVER infirm OF.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 MICROFILM
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
3097,CN.CJ.
Lender's Name HEATINGUNIT(OVER 100,000B.T.U.19.50 ELECTRIC
Lender's Address
• I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 PLUMBING
information is correct.I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
ordinances and state laws relating to building construction, and
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. REFER TO ORD
(We) agree to save, indemnify and keep harmless the City of MISC.- . CONST.TAX
Cupertino against liabilitPg ,
gments, costs and expenses which PERMIT ISSUANCE 10.00
in namet said Cily in consequence of the MECH.
an of th\pe il,x MECH.CONT. LIC.NO.. TOTAL r-f7 TOTAL -7
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