12540 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
aV IL014G APPLICATION & PERMIT
ADDRESS n
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 254
OWNER'$ PLAN CHECK VALIDATION
7� ELECTRIC PERMIT FEE
PHONE y`kb-1�) a�•
CONTRACTORS 12-1 OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME e
MJS$O�•11�P.A"PR-+�rL o. LIGHTING FIXTURES 10.00/1.00
ADDRESS
oms PPLIANCES-RESIDENTIAL 4.00
CONTRAS ��/�� ('
LZA",• 1llt F"ONER �'ZI PANELS 10.00 DATE DATE OF APPLICATION
RCHnscr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
IIP EMP.METER OR POLE INS. 20.00
ASTs
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
CIE .o LICENSED CONTRACTORS DECLARATION /
< u w 1 hereby uffirn that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y (commencing with Section 7000)of Division 3 of the Business and
a n BLDG. ELECT. PLG. MECH.
F w i Professions Code,and my license is in full force and effect. ❑ ❑ ❑
z o,n- License Class Lic.Number Ci VD
o r w Date Contractor 4
Y
¢ a a OWNER-BUILDER DECLARATION ^r/ / BUILDING PERMIT
o s v INFORMATION
w ; a.y I hereby affirm that I so exempt from the Contractor's License MISC.- REFER TO ORD
H u o j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 d vALunilON
Code:Any city or county which requires a permit to construct,alter,
IS ca < improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTE. LIC.NO ELEC.
D¢ requires the applicant for such permit to file a signed statement that rA�SSO'l Ilk�J}j'�L,( ` TOTAL 3 a
PERMIT TO
K
$ he is licensed pursuant n ing provisions of the Contractor's License FLC.-G
H r Law(ChapterProfessions
with Section is 00)exemfttherefion oofthe
f i o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ $ the basis for the alleged exemption.Any violation t ofSection7031S malty STORIES TYPE CONSTR.
by any applicant furs permit subjects the applicant toacivil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than rive hundred dollars(5500).): '
❑ 1,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
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-
builder will have the burden of proving that he did not build or un- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
p
v0
purpose of sathle.). RES IND CON Pe OMar
I,as owner of e property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
li •n •d 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 Law does 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 contractof(s)licensed pursuant to
the Co.tractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
Cl I am exempt under Sec..,B&P.C.for this
reason WATER HEATER W/VENT 6.00
Ownern,.. V- WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WO RKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJ.
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-ZO
Z Z' ❑ Certified copy is filed with the City inspection division.
F O Applicant MISC.- REFER TO ORD. v E) N 1 v E] N�
CC y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL Y E] N❑ v[] N❑
::) Z hundred dollars(SHOO)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL k-, mit is issued, I shall not employ any person in any manner so as to
Obecome subject to the Workers Compensation Laws of California.
C. Datc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? 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 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec.
3097,Cie.C.). s HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50ELECTRIC 3�J'U
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 county PLUMBING
ordinances and state 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 (Over 100,000 BTU(SEE FEE SCM.
above-mentioned property for inspection purposes. 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 way accrue against said City in couseque ce of the PERMIT ISSUANCE 10.00
grand this ermit' MECH.CONT. LIC.NO. MECH.
L 7 TOTAL TOTAL
/v Si Store of ppimant/Contmctof DatE
OFFICE COPY