12261 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
9DILDING APPLICATION & PERMIT
aooREss BUILDING=ELECTRICAL-PLUMBING-MECHANICAL12261
Z y `
OWNS.S PLAN CHECK VALIDATION
�� NAME xA1 DTV. ELECTRIC PERMIT FEE
PRONE
CONTRACTOR'S UTLETS-SWITCHES-RECEP 10.00/1.00
2-
Llc. -P o " - LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
,ONCTORs PPLIANCES-RESIDENTIAL 4.00
CONTRA
1� POZZZ Q PANELS 10.00 DATE OF APPLICATION
ARCHITECT N PANELS (OVER 200 AMP) 20,66 PLACHECK FEE P.C.NO.
OR
ENGINEER„\ LIC Nob SIGNS TRANS. 3.00
ARCH.OR ERG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00 1
APPUCANT'9 MOTORS SEE FEE SCH. `
ADDRESS v hl Gl n
SERVICE CHANGE 20.00
D o O LICENSEDCONTRACTORS DECLARATION
a U U I hereby affirm that I an,licensed under provisions of Chapter 9 ISSUANCE DATE
a w (commencing.with Section 7000).of Division 3 of the Business and BLDG. ELECT. .PLG. MECH.
yProfessions Code,an my license s in full force a d effec ❑ ❑ ❑
z o H License Class _ Lic.Number
2 z r w Date Contractor L
a y f J BUILDING PERMIT
¢ ¢ w u OWNER-BUILDER DECLARATION - INFORMATION
w; u y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/FT.
�. o st Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
� yuCode:Any city or County which requires a permit to construct,alter,
re aa Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. '
O LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
whe is licensed pursuant.to the provisions of the Contractor's License AA /
r z i
Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe /V( �"'i/f
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
L
¢_$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant ton civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,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 do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
+/� Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 s0.FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsara not intended or offered for Sale.If,however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner-
�asA builder will have the burden ofproving that he did not build or im. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
purpose of seleJ. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB omar
prove for
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to Construct the project(Sec.7044,Business LAWN SPRINKLERS:1 INC 6 V.B. 6.00 ASSESSOHS PARCEL NO.
and 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(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec..,R&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy there f(Sec, 00,Lab.C.I
Policy No. Company
O ❑ Certified Copyp hereby fu 'Ir FIRE SPRINK ENERGYTY4
Z Zp -H Candle {(y 'led ns on division. MISC.- REFER TO ORD.
O Applicant - V ❑ N❑ Y ❑ N❑
W CF;RTIIICA'I'E OP EX. PT ION FROM WORKERS' PERMIT ISSUANCE 10.00 PLOOD ZONE A.L.U.C.
W > f COMPENSATION INSURANCE PLG.CONTH. LIC.NO. PLG.
d 0 (This section need not be Completed if the Pe nn it is for ane TOTAL v❑ N❑ V❑ N❑
Z hundred dollars IS 100)or less.) �p
U O 1 certify that in the performance of the work for which this per. Y MECHANICAL PERMIT �101 FEE FEE SUMMARY
LL P mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of Califomia. BUILDING
0 u
Date-Applicant ALTER OR ADD TO MEC 5.00
} to NOTICE TO APPLICANT: If,after making this Certificate of EX-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE t 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 90,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for 2 EXHAUST HOOD(WITH DUCT) 5.00 L1
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
_ Lender's Address
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and County BOILER-COMPO H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to building construction, and
.a hereby authorize representatives of this city to enter upon the g01 LER-COMP IOver 11X1,000 BTU)SEE FEE SCH. MECHANICAL 3
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino agai liabilities,judgm s, costs anh expenses which CONST.TAX
may in an accrue-agai co eq once of the PERMIT ISSUANCE 10.00 p
gratin I 'L MECH.CONT. LIC.NO. MECH.
l!/ TOTAL 3 C'u TOTAL
pp
-Signature of A ¢ant/ lrachar Date
OFFICE COPY ,