12542 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT .
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12542
OWNER'$
NAME PLAN CHECK VALIDATION
'
,J1 y- TY. ELECTRIC PERMIT FEE
/ U Y/Ci PHONE ',
CONTRACTOR'S OUTLETS-SWITCHES-RECEP 10.00/1.00
�.-
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS t PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PANELS 10.00 f) DATE OF APPLICATION
ARCHITECT I PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
Lm.No. SIGNS TRANS. 3.00
ARCH.OR ENG. n/ PERMIT VALIDATION
ADDRESS /Y SPECIALCIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00
ASMOTORS SEE FEE SCH.
ADDREDDRESSS
SERVICE CHANGE 2W
Foo LICENSED CONTRACTORS DECLARATION I
v I hereby affirm that 1 am licensed under provisions of Chapter 9
yZ
w (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
Hyl Professions Codl,-,.�nJ my license is in full force'nd (1'egqt '�L , PI+-p C BLDG. ELECT. PLG. MECH.
G 0 m - License CI's
Lie.Number 3 O// I ot E4
H y r Dateli Contractor < 18�
rt wOWNER-BUILDER DECLARATION BUILDING PEEl
IT
X 3: LL y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
Fuyj Law for the following mason.(Sec,7031.5.Business and Professions PERMIT ISSUANCE VALUATION S/FT.
Code:Any city or county which requirese permit to construct,alter, 10.00 Q -
R ¢ ¢p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NQ ELEC. W.
a_ iL0, requires the applicant for such permit to file a signed statement that TOTAL
w he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
H z r
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
ce the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
m
by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S500y):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole 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. 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 TRAPS.0O SQ FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsamGotintendedoroffered for sale.It,however,the building r GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im. BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Goner
❑ I,as owner of the property,am exclusively contracting with
licensed contractors m construct the project(See. 7044,BusinessLAWN SPRINKLERS-1 INC 5 VB600 Cl El 0 NO.
and Professions Code:The Contractor's License Law does not apply V.S. .
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS- A.) 1,00
contracts Cor such projects with'a contractorts)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 Tggcr No. PARCEL No.
❑ 1 am exempt under Sec. ,B.&P.C.for this
reason WATER HEATERftj�JN-fj6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK F.RS'COMPENSATION DECLARATION WATER TREATING0JtyLQf.CUp-eftin05.0O
I hereby affirm that 1 have a certificate ofemsent to sell'-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
-(j copy thereof(Sce.3800,Lzb.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T Z4
Z Z/ ❑ Certified copy is filed with the city inspection division.
Applicant MISC.- REFER TO ORD. Y [D N❑ Y ❑ NE]
W CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 Q
l -. FLOOD ZONE A.LU.C.
W > COMPENSATION INSURANCE PLG.CorvrR. LIC.NO.
EL 0 (This section need not be completed if the permit is for one TOTAL (p V E] NE] Y 0 N�
::) Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL L) it is issued, sh II not employ any person in any ann��, as to
becomes 6 t �he Workers'C tpensa]i n w u4 51i ornia.
0. Datc Applicant < ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTI T APPLICANT: V ter .king this Certificate of Ex-
empti on, ou should become subject to the Workers'Compensation APPLIANCE
_ 5.00 PLAN CHECK
provisions of the Labor Code, you mus[ forthwith comply with U FEE such provisions or this permit shall be deemed revoked. - AIR HANDLING UNIT FID10,000 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0=C.EM.) 6.00 SEISMIC FEE
1 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,Civ.CJ. t HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name L�
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
• I certify that I have read this application and state that the above V ENTI LATION FAN (SINGLE) 4.00 -
information is correct. I agree to comply with all city and county BOILER-COPztP 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING dL
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH.
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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against aid in consequence of the
granting o(Ihis permi MECH.COAT. LIQ NO. MECH.
Kq
TGTAL TOTAL 3�cry
Slure opplicanl Contractor O e
OFFICE COPY