12335 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLfP.QINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
..,,DING APPLICATION & PERMIT
ADDRI:ss ',
V BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12335
A
Ow R' PLAN CHECK VALIDATION
NAML
�\L ,
s �eHGDNI
QTY ELECTRIC PERMIT FE
E
RAO - CLPOUTLETS-SWITCHES-RECEP 10.00/1.00 HAVE � Q
se
NO*,IV LIGHTING FIXTURES 110.00/1.00
-oNTRAj /ss }GS. C1 PPLIANCES-RESIDENTIAL 4.DO
AOOREs!t s I-�-'
MON PANELS 10.00 DATE OF APPLICATION
ARRCHI ECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO,
ENGINEETf-
uc.No. SIGNS TRANS. 3.00
AARC OR DDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIPEMP.METER OR POLE INS. 20.00
APPLICANT'.
ADDRESS MOTORS SEE FEE SCH.
��
SERVICE CHANGE 20.00 z,20
W o o LICENSED CONTRACTORS DECLARATION
or
u w I hereby affirm that 1 am licensed under provisions Of Chapter _ .S _ ZNJ ISSUANCE DATE
m
(comencing with Section 7000)Of Division 3 of the Business and BLDG. ELECT_ PLG. MECH.
F z Professihins Cade and m license u in full forc5:1 eQert.
Z o 2 - Liccnu as Lic.Number rl K if ❑
o m H Date Contmmor
a m s BUILDING PERMIT
¢ ¢ OWNER-BUILDER DECLARATION
a to u INFORMATION
oo. MISC.- REFER TO ORD
E
; e m I hereby collo that I on exempt
c.7 from the Contractor's License VALUATION S/FT.
FLLoa Law for Any
oriounty which
r. uireso,ermit tocudProcessions PERMIT ISSUANCE 10.00 er
Code Any city or county whish rtyuiture P prior
Loco Issuance,also
4 p re improve,JCrtwluh,or repair any structure,prior to its Issuance, ELEC.GDNTR. LIG NO. ELEC.
-o or requires the applicant for such permit to rile a signed statement that TOTAL �- PEHMIT TO
w he is licensed pursuant to the provisions of the Contractor's License L/ -G�
i
H z Law(Chapter 9(commencing with Section 7000)of Division 3 of the (--
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
re = the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aby any applicant for a permit subjects theplicant this civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not mom than five hundred dollars($512L):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE' 4.00
their sole compensation,will do the work,and the structure is not DCG GROUP RES.UNITS
intended or offered for sale (Sec. 7144, Holiness and Profcsalons 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 dos Such work FIXTURES-PER TRAP 5.00 SO.FL FLOOR AREA TOTAL ACREAGE
•'+/, meets are not intended
owncferedfr provided.If.however,the
improve- GAS-EA.SYSTEM-11NC.4 CUTd ETS 6.00
menus are not intended or offered for vk.If,however,the building
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4(EAC 2.00 BUILDING USE
builder will;nave the burden of proving that he did not build or Ira- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
O I,as owner of the pro toly,am exclusively contracting with F] ❑ E:] C] ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Low does not apply
to an owner of property who builds or improve thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contmeto ts)licensed pursuant to SEWER-SANITARY-STORM EA,2001t/10.00
the Contractors License law. TRACT NO. PARCEL NO.
O I am exempt under Sec. ,13.&P.C.for this WATER HEATER WNENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK Ii RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insum. ZONING
or a certificate of Workers Compensation Insurance,or a certified ENG.SITE NO.
copy there f(p See,3500,Lub.C.).
Policy NO. Company
Q 1 ❑ Certified Copyisherebycurionled. FIRE SPRINK ENERGY T$4
Z Z/ AP❑ Certirice con 's fled w'0 the 'tv 'ssoectinn division. MISC.- REFER TO ORD.
O IP cithI i Y ❑ NE] V ❑ N❑
DC Lo CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE. I 10.00 FLOOD ZONE A.L.U.a.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
_ (This section need not be completed if the permil is for one TOTAL y❑ NE] Y ❑ N❑
hundred dollars IS 100)Or I..) I
U O 1 certify that in the Performance of the work for which this per- QTY. MECHANICAL PERMIT' FEE FEE SUMMARY
IL I- mit is issued,1 shall nm employ any Person i any ma t0
O w been, c eW the Workers' o Adol a a.
Is. Dmc.Y-3-TJ1E_APPlinm /.lC!! ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICE TO APPLICA ,r: If,after making t s Ccrtifcut of Ex-
F-. ? caption,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 such provisions or this permit shall be dee nmd revoked. AIR HANDLING UNIT(TO 10=C.F.M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM) 6.00 SEISMIC FEE
1 hereby affum that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 1 5.00
the performance of the work for which this Permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UN IT I DO,DDO B.T.U.)9.50
�- Lendcri Address - ELECTRIC
I certify that I have read thii application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and scute 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 IOser 100,IXq BTUISEE FEESCH. MECHANICAL
\ above-mentioned properly for inspection purposes.
(We) sgrce to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments,costs and expenses whichCONST.TAX
may in any way ace again i in consequence of the PERMIT ISSUANCE 10.00
gm log oft perm. MECH.CONT. LIG NO. MECH.
TOTAL TOTAL
ilNalure of Ap hca /Contractor Date
OFFICE COPY