12449 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
ADDREI ) APPLICATION & PERMIT 12449
noo:)sj _n l_A-�-
�-Iq �( � PE1�.� C't BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNEa's PLAN CHECK VALIDATION
"AME,� I �D1n.- (CcC6oto
' DTV. ELECTRIC PERMIT FEE
W - 8 z �-91
"ONE
CONTRACTORS I UTLETS-SWITCHES-RECEP 10.00/1.00
NAME /� G�ja6a
M•� � •"� LIC.No. LIGHTING FIXTU RES 10.00/1.00
CONTRACTOR S Ix PPLIANCES-RESIDENTIAL 4.00
ADDRESS,73z)I 1( VIc7 _
/5 VkQ- V PRONE �fl Zt'I PANELS 10.00 GATE OF APPLICATION
ARCHITECT
OR PANELS (OVER 200 AMPI 20.00 PLAN CHELK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
aAmun'EOR n ENa SPECIAL CIRCUIT 5,D0 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPULANT'S MOTORS SEE FEE SCH.
ADOREu V I
SERVICE CHANGE 20.00
02 LICENSED CONTRACTORS DECLARATION
a v I hereby ufOml that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
yam (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT.' I.G.PMECH.
F D z Professions Code,an my license is in full force J f
m o 1 - License CI Lie.Number_ ❑ ❑
o Z H w Uafe Contractor
y s BUILDING PERMIT
SS Bea
OWN R-BUILDER DECLARATION INFORMATION
A. y / I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION
F a.o a Law for the following reason.(Sec.7031,5,B, Lie
Professions PERMIT ISSUANCE 1000 5/FT.
F � iI Code:Any city or County which requires a pemlillocon". t,alter. ELEC.CONTR. LIC.
2 ¢ D improve,demolish,or repair any structure,prior to its issuance,also ELEC.
DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E
$ he is licensed pursuant to the provisions of the Contractor's License
FZi Law(Chapter 9(commeocingwithSection 7000)ofDivision3ofthe PL-d6
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A by any applicant for a permit subjects the applicant toa civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than Five hundred dollars($5 W)J:
O 1,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,AREA,COND. 5.00
Cale:The Contractor's License law does not apply to on owner of
prolwsty who builds or iH,noves thcmnn,and who dues such work FIXTURES-PER TRAP 5.00 sa Fr.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1 INCA OUTLETS 6.00
ments are not intended or offered for side.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
IDI,as owner of the property,am exclusively rontrucling with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7144,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS 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 contraclor(s)licensed pursuant to SEWER-SAN EA.200ft/10.00 ti-
the Contractors License Law. TRACT NO, PARCEL NO.
❑ Ism exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
caner Dale WATER SYSTEM ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. .00
I he rti alfinn that 1 c'uu ggniidum of conwnl to . e'li ed Y ZONING ENG.SITE NO.
or a coli y2Nr11sensation II(surancc,or a ccrtil icd
O Pope flier - "fy.). Ftu IaRa•lP Fiu, ( ��
zl�Certified copy Is hereby famished. r^ tN,B L FIRE SPRINK ENERGY T 24
Z Z ❑ Certified a filed It the city inspection division.
O Applicanl_. � - f�1._./� MISC.- RE O ORD. Y ❑ N❑ Y ❑ N❑
CCN CERTIFICATE 01:17XEMPTION ROM WORKERS'ORKERS' PERMIT ISSUANCE 10.0010 - FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
0- Z 1'rhis defiers need net he completed if the permit is for one TOTAL V❑ N❑ v 1:1N❑
hundmit do11ars(S 100)a less')
U O 1 certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not cmplo any rson in any manner so as to
O L) become subject to the Work �om anon Laws of California. BUILDING
ad Date Applicu ALTER OR ADD TO MECH. 5.00
rn NOTICE '1'0 APPLICANA: If,after making this Certificate of Ex-
F Z 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
U Dch provision,or this permit that be deemed revoked AIR HANDLING UNIT(TO 10/00DOF.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is q Onsir tion lending agency for EXHAUST HOOD(WITH DUCT) 5.00 -
the C.). a of the work foAvlhich its permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.
Lender's Name �1 V'
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
S I certify that I have read this application and state ilial the shove VENTILATION FAN (SINGLE) 4.00
formation u correct. I agree to comply with all city and roomy BOILER-CONP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws relating to building construction, and
hereby authorize reprtsenlatives of this city to enter upon the BOILER-COMP (Over100,0001ITU)SEEFEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgnsents, costs and extimu which CONST.TAX
may U any way acerae agar sl uIJ City in consequence of the PERMIT ISSUANCE 10.00
granting ofthk rmiIt MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
signature of Applicant/Contruci Dam
OFFICE COPY