12074 J
APPLICANT TO FILL IN INFORMATION WITHIN.RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION (� - - - PER MIT NUMBER
malcaNG )11 APPLICATION & PERMIT
A.OR Ess-�•'� G��l
14 1-/ LDI G - ELECTRICAL-PLUMBING-MECHANICAL 12074
NAM.vmER's PLAN CHECK VALIDATION
rvgmE Ty, ELECTRIC PERMIT FEE
wo" PHONE `� '
CONTRA R'
NAME 1� ^ h 'OUTLETS-SWITCHES-RECEP ,10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRgC O
aooR ,C) (]�(�I APPLIANCES-RESIDENTIAL 4.00
V ` \ ' {�(/` PANELS " 10.00 DATE OF APPLICATION
OOgcw PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER _
uc.N6. SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG. SPECIAL CIRCUIT . 5.00 - PERMIT VALIDATION
zio EMP. METER OR POLE INS. . 20.00
ADDRESS s . MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION
Q �u I hereby affirm that'l am licensed under provisions of Chapter 9
v, a u, (commencing with Section 7000)of Division 3 e usiss nd ISSUANCE DATE
FO2 Professions Cod a fens¢is in full a ec neBLDG. ELECT. I PLG. MECH.
z O umi License lass '� Lic.Number ❑ ❑ _
w r w Date' Co Union,
a w a ER ER DECLA AT ON BUILDING PERMIT
o d ° - INFORMATION
X. 3 LL I- I hereby affirm that I am xcmpl from the Contractor's License MISC.- REFER.TO ORD
u O Q Law for the following reason.(Sec.7031,5,Business and Professions VALUATION $/FT.
- PERMIT ISSUANCE
�, Code'.Any city orcountywhiny requires eP construct,alter,
10.00
R a.Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
D, requires the applicant for such permit to file a signed statement that TOTAL ,p
e. w 8 he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
( L�IT
rzQ
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
fro Business and Professions Code)or that he is exempt therefrom and OTV, PLUMBING PERMIT FEE j
W 1- $ the basis for the alleged exemption.Any violation of Section7031.5 re STORIES TYPE CONSTR.
n3 by any applicant fora Permit Subjects the applicant S500LlcaPon civil penalty ALTER-DRAIN 5.00 .
of not mothan five hundred dollars
❑ 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-FLOORROOF, 500
Code:The Contractor's License Law does not apply to an owner of , , , . .
j
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve
ments are not intended or offered for sale:If,however,the building GAS-EA.SYSTEM-11NC:40UTLETS 6.00
or Improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or in- BUILDING USE
Prove for purpose of sale.). REB IND CON PR Other
❑ 1,'as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 El O 1:1licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1. INC 5 V.B. 6.00 ASSESSORS PARCEL 11:1 11
NO.
and Professions Code:The Contractor's License Law docs 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 eontractons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY- .200ft/10.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATERW T
reason 6.00 r
Owner Date WATER SYSTEM w 5.00
I ACC.DATE ACC.FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREAT P. 5.00
1 hereby affirm that I have a certificate of consent to self-insure.
a cerli T
ers'Compens ion I suranc•,ur a cerci icd ZONING ENG.SITE NO.
p L'b.CJ.
o ny,
0 Cetlhe e y furniahe .
Z 2 ❑ Ceris filed ith t e C y pection di 'Sion. FIRE SPRINK ENERGY T 24
O' Applicant MISC.- REFER TO ORD. Y ❑ N Q Y❑ N�
cc W CEOF EXHM1 1 N ' MMWORKERS' PERMIT ISSUANCE , 10.00 FLOOOZONE- A.L.U.C.
W PENSATIO NSURANCE PLG.CONTR. LIC.NO. PLG
1 O (This snot be completed if the permit is for one TOTAL Y No Y N� Zhundred d )orle".)
-) O 1 certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL U 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.
y Date ApplicantALTER ORADDTO MECH. 'BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex- 5.00
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with U FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,ODOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 6.00 SEISMIC FEE
I hereby affirm that there is u'construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued IS MICROFILM
3097,'Civ.CJ. .f HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN:(SINGLE) 4.00 _
information is correct. I agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction„and BOILER-COME(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOI LER-COMP (over 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 - CONST.TAX
may in any wa accrue against said City in conacquene f PERMIT ISSUANCE 10.00
gra nting0 thi nit. �^ CH.CONT. LIC.NO. MECH. �• ��,,yy
Si a
at PPlicant/Contra - Date TOTAL TOTAL_--etl �xxxvvvv
OFFICE COPY