12294 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
•BUILDINGPROJECT IDENTIFICATION PERMIT NUMBER
aDILDING APPLICATION & PERMIT 12294
ADDRESS f�
L) peAT ISMO � , BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
E 5 PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
V UN/`Jv( w PHONE
CONTRACTOR'$ OUTLETS-SWITCHES•RECEP 10.00/1.00
NAME
by, /,ILA -v'�'J®t LIC.No. .rrr0 d LIGHTING FIXTURES 10.00/1.00
CONTRACTDRS IF APPLIANCES-RESIDENTIAL 4.00
ADDRESS p
`O W� vc 1HONE , �7(ep PANELS 10.00 DATE OF APPLICATION
ORCRIT
ECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT - 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
avvuc
ADDR SS
Ess MOTORS SEE FEE SCH.
$ERVICECHANGE 20.00 � ,v/I'✓
w o o LICENSED CONTRACTORS DECLARATION I
a U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a¢ $ (commencing with Section 7000)of Division 3 of the Businessand BLDG. ELECT. PLG. MECH.
r N z Professions C d my license is in full for a�i111 f(aet
z o o Licens�j.'las Lic.Numberd f 7 ❑ ❑ ❑
o z F-9 Dale 1.L,ni a Contractor
a Y 5'� BUILDING PERMIT
¢ ¢ OWNER-BUILDER DECLARATION INFORMATION
A. o a, D - REFER TO ORD
X.g N I hereby affirm that I am exempt from the Contractor's License M I$C.-
w 00< Law far the following reason.(Sec.7031.5,Business and Professions VALUATION $(FT.
_ PERMIT ISSUANCE 10.00
Code:Any city or county which requirese permit to construct,,alter,
QX ¢Q improve,dem Vhah,V!repair any 6INCLUIC,prior IV Its I55V3nCe,also ELEQ CONTR. LIC.NO. ELEC.
i - DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
F
$ he is licensed pursuant to the provisions of the Contractor's License
H 2 i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OTY, PLUMBING PERMIT FEE
It r D the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR.
i ;� by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages a5 BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
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
property who builds or improves thereon,and who does such work YL F IXTUR ES-PER TRAP 5.0 ^ 50.FT.FLOOR AREA TOTAL ACREAGE
r{ ments.,amself throughhisown fferedoremployees, le.If,however,
the
improve GAS-EA.SYSTEM=I INC.4 OUTLETS 6.00 (p
mems are not intended or offered for sale.If, that s the bmldin.
or improvement is Sold within one year of completion,the ownGAS-EA.SYSTEM-OVER 4 IEA.) 2,00 BUILDING USE
builder will have the burden of proving that he did not build or Zr.imRES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTFp, 30.00
❑ 1,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
I icenwd contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 I 6.01) ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLER R .00
contracts for such projects with a conlractons)licensed pursuant m
the Cbntmctor's License Law. SEWER-SANITARY- .00 TRACT NO, PARCEL NO.
❑ I am exempt under Sec. - ,B.&P.C.for this WATERHEATER W/V T 6.00
reason
Owner Date - WATER SYSTEM .00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insum, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof I Sec.3800,Lab.C.� A r
Policy No. CompanyA.
0 ❑ Certified copy is hereby fu niched. FIRE SPRINK ENERGY T 24
Z Z
Of
ifL Ccr co0ys is led ilh the city inspection division.
O Applicantvv-Ats !`__r/1+._�1--_� MISC.- REFER TO ORD. y❑ N❑ Y ❑ N[]
CCN CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 OW FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLO.
a• o (This section need not be completed if the permit is for one TOTAL J!r Y❑ N❑ Y❑ N❑
LD Z hundred dollars(S 100)or IessJ -
) 0 1 certify that in the performance of the work for which this per, QTY: MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued.I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
LU Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Cade, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.1 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
fire performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Cu,CJ.
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
,
v- I.certify that l have read this application and state that the aboveVENTILATION 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(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
abovmmentioned 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 any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting�of this��ermi�. - MECH.CONT. LIC.NO. MECH.
`/Y4J�Xt�s l !��$ TOTAL TOTAL
Signa r of Applicant/Contractor Date
OFFICECOPY