12259 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
\ BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
7- j llca+tT ,DGg, BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1 225
OWNER'S PLAN CHECK VALIDATION
NAME MAJrlj QTY- ELECTRIC PERMIT FEE
vuorvE'2-..•gQ-(6&
CONTRACTOR r_-Z, UTLETS-SWITCHES-RECEP 10.00/1.00
rV LIC.No:3D4*7Z ILIGHTING FIXTURES 10.00/1.00
C-ONTI CTOR'S APPLIANCES 4.00
AGOG ESS '4
0 5 PHONa eQ �y I PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 2000 PLANCHECKFEE P.O.NO.
ENGINEER
' uc.No. SIGNS TRANS. 3.00
ARCH Ess OR ENG. Z 0-e'SPECIAL CIRCUIT 5.00 -Cs PPERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 „ J
ADDRESSTs MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
F o o LICENSED CONTRACTORS DECLARATION 'S-/ •ate JI ., / /
r i w I hereby affirm that I am licensed under provisions of Chapter 9 _ 2L ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
SLOG. E CT. PLG. MECH.
H w i Professions Code,an I license is in full for�an fit". a ! �(,E�
z o m - sac�s Lie.Number Z- IXI m
9 N Date L Contractor W�
I- w
a Y s
¢ ¢ w a OWNER-BUILDER DECLARATION BUILDING PERMIT
o d o INFORMATION
X g: LL y 1 hereby affirm that I am MIS
exempt from the Contractor's License C.-1J REFER TO ORD
Fu0 J Law forihe following reason.(Sec.7031.5,Businessand Professions pERMIT'ISSUANCE 70.00 VALUATION $/FT.
N Code:Any city orcounty which requires a perml toeonsirud,dre, -
rea,¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. I J D
¢ requires the applicant for such permit to file a signed statement that TOTAL ;�_L,1,w m w he is licensed pursuant to the provisions of the ContractorPERMIT TO
Contractor's License
F z a Law(Chapter 9(commencing with Section 7000)of Divisiolt 3 ofthe
E 4 O Business and Professions Code)or that he is exempt therefrom and
¢ N 0 the basis for the alleged exemption.Any violation of Section 7031.5 QTY. PLUMBING PERMIT FEE
A , by any applicant fora permit subjects the applicant toa civil penalty STORIES TYPE CONSTR.
of not more than five hundred dollars($500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 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 sWcture is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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-
mentsarenotintendedorofferedforszle.R.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 an- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00RES
mmIN Other
O L as owner of the property,hexclusively contracting with
licensed contractors ID construct the F-1 ❑ ❑ 1:1 El e project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ABSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to antr owner of property who builds or improves used u and whot to LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant t0
the Comractnr's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
O lam exempt,uneer Sec. ,B.&P.C.I'or this WATER HEATER W/VENT 6.00
Owner
weer Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
Polk ihcr ( e 0 any AIG uAWZS{//R£
Policy N any (.
0 ❑ Ccn ificJ y'sIrcb f rmsheJ.
Z � Certifi fi w'Ih the city inspection division. FIRE SPR INK ENERGY T@4
O Applicant-�� MISC.- REFER TO ORD.IF Y NEI v ❑ NQ
D7 - CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.O.C.
LU - COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG
CL O (This section need not be completed if the permit is for one TOTALv N Y E] N❑
Z hurried dollaa($100)or Ico.)
U O 1 certify that in the performance of the work for which this per- QTY. FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to MECHANICAL PERMIT FEE
O W become subject to the Workers'Compensation Laws of California.
y Date APPLICANT:
I ALTER OR ADD TO MECH. �' 5.00 BUILDING
} to DifleNOTICE TO APPLICANT: If,after making this Certificate of lix-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this pemlit shall be deemed revoked AIR HANDLING UNIT(TO 10,OODQF.M.) 4.00
T 0-
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm unit 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.
MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UN IT(OV E R 100,000 B.T.U.)9.50 ELECTRIC so �
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 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 this
representatives of ths city to enter upon the MECHANICAL
above-mentioned property for vespopurposes. BOILER-COMP (Over,100,000 BTU)SEE FEE SCM.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which yu CONST.TAX
m m my wa a e,against said City in consequence of rho PERMIT ISSUANCE 10.00 6
gra tin O his en MECH.CONT. LIC.NO. MECH.
/2•Z r g(� TOTAL
Sig ueof ApplI.�C TOTAL
OFFICE COPY