5512 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION . PERMIT NUMBER-
!1 BUILDING APPLICATION & PERMIT
aooREss I x
l I S BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 5512
OWNER'S PLAN CHECK VALIDATION
r a E N
rnON /J1/_ QTY. ELECTRIC PERMIT FEE
♦�7h tj PHONE-lostP
I
CONTRACTOR OUTLETS-SWITCHES-RECEP 5.00/1.00
A"Muc.rvo. LIGHTING FIXTURES 5.00/1,00
ADOTRacroR's APPLIANCES- 4.00
a OOREs r
RONE _X 5 PANELS 5.00 DATE OF APPLICATION
ARCHITECT - SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
, LIC.rvo. SIGNS TRANS. 3.00
nooeEss G.ENCIRCUIT 5.00 PERMIT VALIDATION
ZIP FEMP.METER OR POLE INS. 15:00
APPLICANTSADDRESS - MOTORS SEE FEE SCH.
• SERVICE CHANGE 10.00
o¢ i
Foo LICENSED CONTRACTORS DECLARATION
G u� I hereby affirm.that I am licensed under provisions of Chapter S ISSUANCE DATE
ma (commencing with Section 7000)of Division 3 of the Business and
a 1� BLDG. ELECT. PLG. MECH.
F w Professions Cod}..!r)A y license is in full forceT�y!"o34 1 ❑ ❑ ❑ El
z a m- icenu I ss_(j=�=1__Lic.Number 9�
O n t: Dam r4�.Lg Comractor AL'L_ _,AIaE�a
s - 1 BUILDING PERMIT
¢ tea OWNER-BUILDER DECLARATION
o a u INFORMATION
wg y 1 hereby affirm that I am exempt front the Contractor's License MISC.- REFER TO ORD
F u o ", Law for the following reason.(Sec.7031.5,Busincssand Professions PERMIT ISSUANCE 6.00 VALUATIGN $/FT.
as Code:Any city or county which requires a permit to construct,alter,
ac to G 2O improve,demolish,of repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
to
O LL requires the applicant for such permit to file a signed statement that - TOTAL PERMIT TO
w he is licensed pursuant to the provisions of the Cantmlanr s License JAI
i
Law(Chapter 9(commencing with Section 7000)of Division 3 of t he /, &ff
a. Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT
the basis for the alleged exenlplion.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3$ by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN (EA.) 4.00 ,Iy�p 1f FiB-✓
of not more than O -
five hundred dollars(ES00).): GI IIIIB
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their Sale 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. 4.00
Code:The Contractors License law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided thatsuch improve- EA. -11NC.40UTLETS 4,00 '
memGAS-EA
s are not intended or offered for sale.If.however,the building -
or improvement is sold within one year of completion,the owner- GAS-EqSYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or ion. .- RES IND CON PO Ome.
prove for purpose of sale.). I INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting with El E] E] [:] ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contmcls for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/8.00 TRACT No. PARCEL NO.
❑ Iain exempt under Sec. ,B.&P.C.for this
WATER HEATER WIVENT - 4.00
reason
Owner Dam WATER-SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKI:RS'COMN?NSATION USCI.ARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a cerlificale of consent In self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,LAC.). F
Policy No. &npany_C.r,1
O 0 Certified copy is hereby famished. FIRE SPRINK ENERGY T-24
z Z Cerlif copy is lad UI ci 'Peet' div'
.It MISC.- REFER TO ORD.
APPhcard Y ❑ N❑ y❑ N❑
� y CIiR' PICA'1'I>OF Ii%L'AfYTION FROM WOR PERMIT ISSUANCE •6.00 FLOOD ZONE A.LU.C.
>_ COMPENSATION INSURANCE PLc.coNTR. ❑c.NO. PLD.
d O (this section need not be completed if Ih_e permit is for one TOTAL Y❑ N❑ Y ❑ N
::) Z hundred dollars($100)or less.) a
U O 1 certify that in the performance of the work for which this per- ATV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F' mit is issued,I shall not employ any person in any manner so as m
U become subject to the Workeri Com ensatinn Laws ol'California.
O w ) p BUILDING 5�
y NOT Applicant ALTER OR ADD TO MECH. 4.00
} N NOTTO APPLICANT: If,after making this Certificate sa ion
Z
coalition,viion you should become subject to the forthwith
Compensation APPLIANCE 4.00 PLAN CHECK
such
provisions io the labor Cit Shall
you must forthwith comply with FEE
U such provisions or this permit shzll be deemed revoked. AIR HANDLING UNIT PTO tOp00CF.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=r-F.M.) 5.00 SEISMIC FEE fa
I hereby affirm thin there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performanceofthe work for which this permit is issued(Sec. MICROFILM
3097,Cw.CJ. I HEATING UNIT PTO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information is correct..)agree to comply with all city and county PLUMBING
meinarees and slate laws relating to building construction, and BOILER-COME(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over t00,0oOBTU)SEE FEESCH. MECHANICAL
Shove-mentioned 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 CONST.TAX
may any way rue against said City in con quence of a PERMIT ISSUANCE _ 3.00
gr:m n o(this pc it.• MECH.CONT. LIC.NO, MECH.
(Q S TOTAL TOTAL
t n I App cant/Conmucto ate
OFFICE COPY