12469 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
,s✓ ` BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
-� 9UILDING APPLICATION & PERMIT
12469
ADDRESS R
Z ZZIG pp' VBUILDING—ELECTRICAL—PLUMBING—MECHANICAL
rNA
ER'5 PLAN CHECK VALIDATION
�] CITY. ELECTRIC PERMIT - FEE
ONE
� eRncTs [, UTLETS-SWITCHES-RECEP 10.00/1.00
F • uC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S SC PPLIANCES-RESIDENTIAL 4.00
ADDRESS /' r• �` (� �//��.'J
30GR Frncfb5r PRONE 1 /LYC PANELS 10,00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,OQ PLAN CHECK FEE P.C.NO.
O
OR
ENGINEER
' LIC.No: SIGNS TRANS. 3.00
ARCH.OR ENG. $PECIAL CIRCUIT S.QQ PERMIT VALI DATION
ADDRESS
ZIP --t—TEMP.METER OR POLE1 20.00
APPLICANT'S MOTORS E FEE SCH.
ADDRESS ✓IIC� /
SERVICE CHANGE 48,20.00
w o o LICENSED CONTRACTORS DECLARATION - J/
a u I hereby affirm that I am licensed under provisions of Chapter 9 Q ISSUANCE DATE
N rt n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. _
25 z Professions Code, y license is in full force ary�pf
z 0`� - License C Lie.Number - `+V TL� �❑ El' ❑
9 z F o Dale Contractor r
a Y s � BUILDING PERMIT
¢ ¢w ¢ OWNER-BUILDER DECLARATION INFORMATION
u MISC.— REFER TO ORD
w;A. I- 1 hereby affirm that I am exempt from the Contractor's License
O Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00I'd
_ VALUATION SIFT.
ELL Code:Any city or county which requiresa permit to construct,alter,
SE u< improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC, gg
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
X $ he is licensed pursuant to the provisions of the Contractor's License
1- ¢ >0 Law.(Chapter 9(commencinge,ith Section 7000)of Division 3ofthe 'ENA &_�L�
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
M i D
¢1- the basis for the alleged exemption.Any applicant
of Section en LS STORIES TYPE CONSTR.
by any applicant fora permit subjects S500).licant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).): '
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP REB.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
.IA v property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his awn employees,provided that such improve- GAS-EA.SVSTEM-1 6.00
r mems 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. .RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIALWASTE 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 AWESSORSPARCELNO.
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 for such projects with a contrachms)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,R&P.C.for this WATER HEATER W/VENT 6.00
reason
,Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self-insure, - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation nsumnee,or q certifmd
copy thereof{5�p}500,Lab.CU. 7!4 C_�1�
Policy No.�l_-1./l Compath.
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z ZO *Certified c I is filed wit the c' i sp tion division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
Applicant Y N Y N
CCN CERTIFIC TE OP EXEMPTIO FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A,L,U,C.
lll > COMPENSATION IN URANCE PLG,CONTR. LIC.NO. PLG.
cL 0' ('this section need not be Completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
:) Z hundred dollars(SI00)or less.)
L) O 1 certify that in the performance of the work for which this perCITY. MECHANICAL PERMIT FEE FEE SUMMARY
U. mit is issued,I shall not employ any person in any manner so as to
0 U become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
t.. ? emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V 'such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10MC.F.M.) 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.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC �`
S Lender's Address
1 certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00 '
a information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 6.00
w hereby authorize representatives of this city to enter upon the
BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
shove-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 CONST.TAX
may in way accrue st se try in con quem of the PERMIT ISSUANCE 10,00
gra Of his perm; - MECH.CONT. LIC.NO. MECH.
-` to p TOTAL TOTAL
\X' i lure Df Applican Contractor ale 8
OFFICE COPY ,