12333 //I1
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN CNLY !
BU LDING PROJECT 1 DENTI F[CATION PERMIT NUMBER
BUILOING Y APPLICATION & PERMIT
ADDRES%D O� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 12333
OwNER9 / OG PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
.5 !NE D N NON ONE
CONTRACTORS Ca-/ UTLETS-SWITCHES-RECEP 10.00/1.00
NAME r
44 -�i0CC//4�` Ice No. 3373(70 LIGHTING FIXTURES 10.00/1.00
/DDRESSTORs yJ(��6,41Y �d APPLIANCES-RESIDENTIAL 4.00
�/1(- S/ , PHONE A?d Z/ PANELS 10.D0 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
ADDRESS ENc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS PJM FEE SCH.
ADDRESS
SERVICE CHANGE p 0.00 O / / /(' 7
W¢0 20 LICENSED CONTRACTORS DECLARATION
< u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
z (commencing with Section 7000)of Division 3 of the Business and
G ¢ n - dt BLDG. ELECT. PLG. MECH.
H '^ Profession Cod n my licem i is in full fort d d. ❑ ❑ ❑
z o u2' License lav se is Number
9 z r°u� Dale - Contractor �/,q /
P: r f • BUILDING PERMIT
¢ ¢ u u OWNER-BUILUF,R DECLARATION INFORMATION
wIg- 1 hereby affirm that I am exempt from the Contractor's Licenu M C. REFER TO ORD
r c-0 Low for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUAN 10.00 6 - VALUATION S/FT.
Code:Any city or county which requires a permit to co sto-,al",
R2¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. EL p O --
- D u requires the applicant for such permit to File a signed statement that T 1 �J PERMIT TO
K
he is licensed pursuant to the provisions of the Contractor's License r
H x t
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe EGcz-7
< Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERM
the basis for the aIle FEE
¢ = S ed exemption.An
g e y violation of Stetson 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN TE .15.00
ofnot more than five hundred dollars IS500j :
❑ I,as owner of the property,or my employees with wag.as BACK FLOW PROT C .DEWE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7094, Business and Professions DRAINS-FLOOR,RW,AR EA,COND. 5
Code:The Contractor's License Law does not apply to an owner of
. property who builds or improves thereon,and who dues such work FIXTURE P(P T P 5.00 ga PT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale,If,however,the building GAS-Ek.S -11NC.40UTL S 6.00
or improvement Is sold within one year of completion,the owner- GA E S EM-OVER 4( .) 2.00 9UILOmG uSE
builder will have the burden of proving that he did not build or ire- REB IND CON PB Other
prove for purpose of sale.). IN U LWASTE INTE . 30.00
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044, Basins L WN S RIN KLERS-i C 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions code. rhe Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who AWN SPRINKLER VER 5(EA.) 1.00
contracts for such projects with a contractions)licensed pursuant to SEWER-SANIT -STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACG DATE ACC.FILE NO.
WORKERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to selRnuum ZONING
or a certificate of Workers Comp b nc Wt&d ENG.SITE NO.
--� wpy the��pp,,f( j��j'1�0�gj��{gM1 CJ. L
. Policy N7 p .tin! Y
(] ❑ Ccrli led copYl eby furnisheJ. FIRE SPRINK ENERGY T 2
Z ❑ CertiF o flu wi h I m city inspection AWision. MISC.- REFER TO ORD.
O A111,cant Y N V N�
~ rn PERMIT ISSUANCE 10.00
- CER'1'IFICATEOF EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
L COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG.
CL 0 ( is section need not be completed if the permit is for one TOTAL V E] IN V[:] N❑
hundred dollars IS 100)or less)
U O 1 certify that in the performance of the work for which this Ni- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
O r) become subject to the Workers'Comipensation Laws of Calornia.
y Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} rA NOTICE TO APPLICANT: If,after making thin Certificate of Ex-
F 2
sorption,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 deemed revoked AIR HANDLING UNIT(TO 10,0MCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00CEM) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the pero097, cance of the work for which this permit is issued(Sea HEATING UNIT(TO 100,000 B.T.U.) 6.00 MICROFILM
Lender's Name
Lender's AddH EATI NG U N IT(OV ER t 00,000 B.T.U.)9.50 ELECTRIC
I C Q !
ress
to 1 ocnI fy that 1 have read this application and stale ihot the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and cowvy PLUMBING
ordinances and state laws relating to building construction, onJ BOILER-ODMP(3H.Ror100,D00B.T.U.) 6.00
hereby authorize representatives of this city to eater upon the BOILER-COMP IOvar 100,000 STU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection parpous.
(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 any way accrue,againt said City in consequence of the
gra g of is permit n�� MECH.CONT. LIC.NO. MECH.
`Y/C4?11� - TOTAL TOTAL
Store of Applicant/Contractor Date
OFFICECOPV