12275 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 12275
ADOREss
_ BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"AMEICIA OTY. ELECTRIC PERMIT FEE
PRGNE 3
CONTRACTORS y UTLETS-SWITCHES-RECEP 10.00/1.00
t Lm.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
Ia �/� PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT //1, PANELS (OVER 200 AMP) 20,00 PLAN CHELK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
AODRE59 ENG. SPECIAL CIRCUIT 6.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH. /I„'y—•- J
C,et,,,, T11 ,,./ SERVICE CHANGE 20.00
o o LICENSED CONTRA ORS DECLARATION l
a i w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
h G (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLO. MECH.
HD z Professions Cole, d my li c se is in full force and effeCl_0 License Class Lie Number - ' 7 ❑ ❑ ❑
9 H w Dam Conduct., L
¢ y Z
¢ ¢ w a OWNER-BUILD17R DECLARATION BUILDING PERMIT
A0 a UINFORMATION
m3: ,� _ 1 hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
u O v� Law for the following moron.(Sec.7031.5,Busioessand Professions VALUATION S/FT.
H — v+] Cale:Any city or moot PERMIT ISSUANCE 10.00
y which regwresa permit to construct,alter,
¢ ¢ ¢ p improve,demolish,or repair any❑rudure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
e E, requires(be applicant for such permit to file a signed statement that TOTAL PERMIM
w M
$ he is licensed purmant to the provisions of the Contractor's License
H z Q Law(Chapter 9(commencing with Section 7000)of Division 3o Rhe L-1
i E o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
EE H the basis for the alleged exemption.Any violation of$ection 7031,5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to is civil penalty
of not more than five hundred dollars(5500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 Dee.GROUP RES.UNITS
their role 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 dm such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
1 himself or through his own employees,provided that such improve-
F, mems are not intended ser offered for sale.If,however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
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. 3000 RES IND CON PB Direr
Cl 1,as owner of the property,am exclusively contracting with . ❑ ❑ 0 0 ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASS 55oRS PARCEL NO.
and Professions Code:The Contractor's Lirensc law dues not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contract.,',License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.—,BAP.C.fur this WATER HEATER W/VENT 6.00
reason
Owner Dam WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hemby affirm that I have a certificate of CGmwRt to self-insure,
or a certificate of Workers'Compensalum Insurance,ser a certified ZONING ENG.SITE NO.
copy torrent(Sec.3800,Lab.C.L /
Policy No. Company fir H-C�
U J ❑ Certil Ted copy is hertby faro shed.
Z ❑ Certified led with the 'ity in'pection division, FIRE SPRINK ENERGYTTa
O Applicant y MISC.- REFER TO ORD. Y[] N❑ Y ❑ NEI
DCN CERI'IF ICA'IT OF F.XI PTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
lld > COMPENSATION INSURANCE PLG.CONTR. SSC.No
PLG.
CL Z I Ibis section need not be completed if the permit is for one TOTAL Y E] NEI Y ❑ N
hundred dollars IS 100)or Icss.)
U O I certify that in the performance of the work for which this per- Qom. MECHANICAL PERMIT FEE FEE SUMMARY
LL f mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
n Dal` ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} In NOTICE TO APPLICANT: If,after making this Cenificale of F,x-
F ? emption,you should become subject to the Workers'Comlxmsation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions m
or this permit shall be deemed evoker]. AIR HANDLING UNIT(TO 10=r—F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNff(OVER 10=C.F.l .) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the Uhu nance of the work for which this permit is issued(Sea HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I have read thuappllcallon andstale that the above VENTILATION FAN (SINGLE) 4.00
information u correct.I agree to comply with all city and county PLUMBING
ordinance and slate laws relating to building construction. and BOILER-COMP(3 H.P.o-100,000B.T.U.) 6.00
hereby entionsed reperty for ins inspection
this city es to
upon the BOILER-0OMP tOver 100,000 BTU)SEE FEE SCH. MECHANICAL O ��
above-mentio r 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 PERMIT ISSUANCE 10,00 �(� ` CONST.TAX
may in en way accrue against said City in consequence of the
grantingo h per it MECH.CONT. LIC.NO, MECH.
TOTAL j�� TOTAL
Signature (Applicant 44144
onl for ate
�FFICE COPY