12326 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION 'PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADD ss BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
d 12326
/� OwNER'S PLAN CHECK VALIDATION
NAM
C.N OTY. ELECTRIC PERMIT FEE I
conTRAcroRs PHONE UTLETS-SWITCHES-RECEP 10.00/1.00
N/,ME • /
r7 f LI o. LIGHTING FIXTURES 10.00I1.00
CONTRACTORS oRS APPLIANCES-RESIDENTIAL 4.DO
uzNEA0-77 - PANELS 10.00 DATE OF APPLICATION
A c
OR PITMC - PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE ITC.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
1.
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP FEMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
'09 LICENSED CONTRACTORS DECLARATION
a v u .1 hereby afflon that I am licensed under provisions of Chapter 9 ISSUANCE DATE
ai G m (commencing with Section 7000)of Division 3 of the Business and .BLDG. ELECT. PLG, MECH.
H n Professions Code,and y cense u in full forte a� f
c O u,- Liccn.m Class Lia booth, ❑ ❑ ❑
O N H w Date-q_,.,..,G_Conlmclor
a i 'L ab BUILDING PERMIT
Ic ic w a OWNER-BUILDER DECLARATION
o A U MISC.- REFER TO ORD INFORMATION
w S a- I- I hereby affirm that I am exempt from the Contractors License - VALUATION 5/FT.
F u o g Law for the following reason.(Sec.7031.5,Berinessand Professions pERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
sa p improve,demolish,or repair any structure,prior to its essence,also ELEG CONTR. LIC.NO. ELEC.
0¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
CIL
$ he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)ot'Diveion 3 ofthe PL--66-
a Blniness and Prokuiov Cale)or That he is exempt therefrom and DTV. PLUMBING PERMIT FEE /
r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; by any applicantfor a permit subjects the applicant toe civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not mom than fvehundred drBars($500)J:
❑ 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 OCC.GROUP RES.UNITS
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
prol,aUy who huilds or improves themon,and who docs such wurk FIXTURES ES-PER TRAP' 5.00 ser FT FLOOR AREA TOTAL ACREAGE
himself or through he own employees,provided that such improve- '
r' ments ore not intended or of for sale.I(,however,the budding GAS-EA.SYSTEM-I IN C.4 OUTLETS 6.00
or improvement is sold within nue year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for pose of sale.). INDUSTRIAL WASTE INTER. 30,00 RES Irvo CON Pe Omar
purpose
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPARCELNT
end Professions Code:The Contractors License Law docs mol apply -
to an owner of propo0y who holds or improves thereon.and who LAWN SPR INKLERS-OVER 5 ( 1.00
contracts for such projects with a conlacoms)licensed pursuant to -
theContractor'sLicenseLaw. SEWER-SANITARY-STOR D/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT -
reason
Owner Date WATER SYSTEM 5.00 ,DATE ACC.FILE NO,
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP.
I hereby affirm that 1 have a ceHificate of consent to self-inose. ZONING or a certificateow
mance,of Workers'Compensation Inrance,or a certifiedTMK 'ENG.SITE NO.
cope moron y5cc. n.c.l.S f7lfn p a ���1C>{i
Policy Lr Ay any-�.•=s-'-"-'�
O ❑ Cc the c is hereby fu m FIRE SPRINK ENERGY Tda
Z ❑ Certifie py d tis a city ins cion division. MISC.- RTO OR D.
p'y, Applicant ,g;�yaa�` Y❑ N❑ Y ❑ N❑
CN CERTIPICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 Q FLOOD ZONE A.L.0 C.
.LU COMPENSATION INSURANCE PLG.CCNTR. LIC.NO. pUG, / aa•
CL O IT Section need not be completed if the permit is for one TOTAL Y❑ N❑ Y,❑ IN E]
Z) Z hondmd dollars IS IW)or I .)
U O 1 certify that mi the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL f mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers Compensation Laws of California.
LU Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emptier,you Should become subject to the Workeri 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=C.F.M) 4.00
CONST RUCTION LENDING AGENCY AIRHANDLING UNFr(OVER 10pWC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
theance of the work,or which the pemtit u issued(Sec.
3097,,Civ
CIV.CCa. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Nam
e HEATING UN IT(OV ER 100,000 B.T.U.)9.50 _
Lender's Address ELECTRIC
Ieertify matlhave real this application and vete that the above VENTILATION FAN (SINGLE) 4.00
t iY information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-CONP(3 H.P.or 100,000B.T.U.) 6.00 (O
sem, hereby authorize representatives of this city to enter upon the - s
xbcve
ovmentioned property for inspection purposes. BOILER-COMP (Or 100,000 BTU(SEE FEE SCH. MECHANICAL,
(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"my way accrue inst said City in consequence of the
gran tinofth' c il. MECH.CONT. LIC.NO. MECH.
�2, ,a_ TOTAL TOTAL
Signature of Applicant/Contactor Ualc'
. OFFICECOPY