12324APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION U PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
12324
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ADDRESS
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OWNER'S
NAME
S -1-4,41L
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHONE
CONTRACTOR S
NAM
'IE r,LJtC!/([J uc. NO.
UTLETS -SWITCHES -RECEP 10.00/1.00 /Q
LIGHTING FIXTURES 10.00/1.00
ACroRs
ADDRESS P ,A_r /lwws..
ADDRLA �1r/�V
APPLIANCES - RESIDENTIAL 4.00
10.00
PHONEPANELS
a Moab
DATE OF APPLICATION
ARCHITECT
OR
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
ENGINEER -
uc.No.
'
SIGNS TRANS. 3.00
ADDDRESS ENG./
-SPECIALCIRCUIT 5.0Q
PEflMIT VALIDATION
EMP. METER OR POLE INS. 20.00
ZIP
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ADDRESS
ADDRESS
MOTORS 'SEE FEE SCH.
SERVICE CHANGE 2000.
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/ sY//// / / U Y
LICENSED CONTRACTORS DECLARATION
I hereby affnn that I am licensed under provisions of Chapter 9
ISSUW! DATE
(commencing with Section 7000) Of Division 3 of the Business and
Professions Codo license is in full fore- a d u ect
License Cla - Lic. Number
Date Contractor
BLDG.
❑
ELECT
PLG. MECH.
❑ ❑
BUILDING PERMIT
INFORMATION
I r
OW NE -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License
Law for the following reason. (See. 7031.5, Business anti Professions
Code: Any city or county which sequitur a permit to constant,, also
palm to d s issuance,ent talsohat
improve, helapplic, Or repair any structure, file
requires the applicant for such permit to file a signed statement License
provisions of the ) ofDivision License
he is licensed 9(copursuant to (commencing
Bmine. and Processions Code) or Section 7000)of Dthsrefrom the
Business and Professions Cade) of tAnt he is and
_
MISC. - REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 10.00
ETEC CONTR. LIC. NO.
ETEC. �q (�Y/(�
TOTAL s�C S
PERMIT TO
ZT
DTV, PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the tion of ectio 70
of Section
the alleged ermit
by.nyisfor
by any applicant fora permit subjects S50O).licant ma civil penalty
subjectsmalty
ubjetsthny eaplica
of not more than five handfed tlollars (5500).):
ALTER-DRAIN-WATER(EA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sola 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 (Sea 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
SQ FT. FLOOR AREA
TOTALACREAGE
himself or through his own employees, provided that such improves
ments are not intended or offered tors,I,, If, however, the building
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is Sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose ofsale.).
❑ 1, as owner of the properly, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.) 2.00
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
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
ASSESSORS PARCEL NO.
contracts for such projects with a contractof(s) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec.-. B &P.C. for this
WATER HEATER W/VENT 6.00
reason
Owner Date
WATER SYSTEM 5.00
ACC. GATE
ACO. FILE N0.
MPEN ATIO . LARATION
WATER TREATING EQUIP. 5.00
*WORKERS'
rm lh t a 'c 1 consent toselbinsure,
oW I n Insuranceoraertck
ZONING
ENG. SITE NO.
PCompany
hr f fished.
FIRESPRINK
ENERGY T-24
J 'th the city inspection division.
'i
Applicant
5MPLe
Y ❑ N❑
Y ❑ N❑
MISC.- REFER TO ORD.
CERT'OFEXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
PLG,
TOTAL
NSATION INSURANCE
(This section need not be completed if the permit is for one
Y❑ N❑
Y❑ NC]
OTY MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars (S 100) or IS".)
I certify that in the performance ol'the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
LDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH, 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers'Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
APPLIANCE 5.00
AN CHECK
E
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10MC.EM.) 6.00
SMIC FEE
[ELECTRIC
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
CROFILM
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.) 9.50
?_-Vu
Lender's Name
Lender's Aderess
1 certify that I have read this application and state that the above
Information is correct. I agree to comply with all city and county
ordinances and state laws relating t0 building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER- COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 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 harmless the City of
Cupertino ag 'n0 Bahilities, judg cost $ and expenses hick
may i ay accrue agar said City in come, ence f e
gr 0 5 e 1
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO. TOTAL
TOTAL
Sig lure f App man[ Contr etor to
J / OFFICE COPY