12024APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
AIUI LDING PROJECT IDENTI OTION
APPLICATION & MIT
BUILDING - ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
12024
N
aculli r
ADD.;
/d
OWNER'5
NAME
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
•' PHONE
DATE OF APPLICATION
S
NAAME/R'ac*oR SC's
LIC. No.
OUTLETS -SWITCHES -RECEP 10.00/1.00
ILIGHTING FIXTURES 10.00/1.00
C-DNTR CTORS
ADDRESS /
/./alga /�'LGWe-0--Le PHON -6y""I"'
[APPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
ARCHITECTPANELS
OR
E NGINE ER
LIC. NO.
(OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
AARCH. OR DDRESS ENG
SPECIAL CIRCUIT 5.0D
PERMIT,, V11111 P.TION
-+1PN
EMP. METER OR POLE INS. 20.00
'v ZIP
„ T
2 � '� '�,�•
APPLICANT
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
-PyO CUpQ
LI v ED CONTRACTORS DECLARATION
ono
I hereby affirm that 1 am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
Professions CtG . license is in full for IQfl'ect.
Class CC Lic. Number
BLDG.
❑
ELECT.
F-1
L MECH.
1:3
Da[a�� _Contractor
BUILDING P RMIT
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5. Business and ProfessionsPERMIT
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires lire applicant for Such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
INFORMATION
MISC. - REFER TO ORD
VALUATION $/FT.
ISSUANCE 1000
.
ELEC. CONTR. LIC. NO.
ELEC. '
TOTAL
PERM I TO
OTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
STORIES
TYP NSTR,
the basis for the alleged exemption. Any violation of Section 7031.5
1
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($5001):
ALTER -DRAIN -WATER IEA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
FIXTURES - PER TRAP 5.00
SD. FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve-
mentsore not imendedoroffered for sale. If, however, the building
GAS-EA.SVSTEM-11NC.40UTLET$ 6,00
aF improvement is sold within one year of cam Plclian, the owner-
builder will have the burden of proving that he did not build or an..
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDIN USE
RES IND 0 PB Other
❑ . ❑ ❑ ❑ -
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
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- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSOR7 PARCEL NO.
contracts for such projects with a contractoos) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ Ino exempt under Sec.-, BAP.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORK ERS'COMPFNSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure,
Or a certificate of Workers Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab.C.).
Policy No. Company
FIRE$PRINK
ENERGY T$4
❑ Certifie"her!byd.
❑ Cer'cttion Jivisior.MISC.-
Y ❑ N
Y ❑ N❑CERTIN
REFER TO ORD.APPIic
FROM WORKERS'
PERMIT ISSUANCE 10,00 r
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the permit is 1'or one
Y ❑ N❑
Y ❑ N❑
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dallais ($100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any mannerso as to
BUILDING
become subject to the Workers' Compensation Laws of California.
Doc APplioant
NOTICE TO APPLICANT: If, after making this Certificate of Ex.
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
emption, you should become subject m the Workers' Compensation
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10,0MC.F.M.) 4.00
AIR HANDLING UNIT (OVER I0)000C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work dor which this permit is issued (See
3097, CN.C.).
MICROFILM
HEATING UNIT (T0 100,000 B.T.U.) 8.00
HEAT] N G UN IT (OV ER 100,000 B.T.U.) 9.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and slalC that IM1C abOVe
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
g01LER-COMPI3 H.P. or 100,000 B.T.U.) 6.00
801LER•COMP lOver IDO,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. -. REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against mid City in consequence of the
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO. MECH.
granting this permi
TOTAL
TOTAL
Signature of AppfillnitJMutractor ate
OFFICE COPY