12209 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
BUILDING -ELECTRICAL?PLUMBING-MECHANICAL 1220
Owry ER'S PLAN CHECK VALIDATION
"AME fJ 36Liq QTY. ELECTRIC PERMIT FEE
e �a �� 1�Qu PRONE
cONERA ORs UTLETS-SWITCHES-RECEP 10.00/1.00
No. Q LIGHTING FIXTURES 10.00/1.00
r. NTRADTo s
DDRESS APPLIANCES-RESIDENTIAL 4,00
A
l CIL PRONE •� PANELS 10.00 DATE OF APPLICATION
ARCHITECTOR PLAN(OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.
DD ESS ERG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP' TEMP.METER OR POLE INS. 2 0
APPLICANTS MOTORS SEES
ADD]
SERVICE CHANGE 20.
wo o - LICENSED CONTRACTORS DECLARATION
a i w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y a e_ (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
D z Professions Cod =}L y license is in full fo U5,1L VU"
oi m o Littns ('lass_ Lic.Numb-..
r w J Date Cootracto
a Y BUILDING PERMIT
¢ ¢w¢ OWNER-BUILDER DECLARATION
A 0 a u INFORMATION
w �LL I- I hereby uRinn that I am exempt Iron the Contractor's License MISC.- REFER TO ORD
a- 03.1
Law for life following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE VALUATION S/FT.
Code:Any city Dreamily which requires a permit to construct,alter,
10.00 Q-
ceQ Q p Improve,demolish,or repair any structure,prior to Its Issuance,also LEC.CONTR. LIC.NO. ELEC. (.0
a requires the applicant for such permit to file a signed statement Iha OTAL to�46A PERMIT TO
//
n w m he is licensed 9(commencing
pursuant n the provisions of 700 Contractor's License L �11Z7 /��� /"PC�lT
H z a
Law(Chapter 9(commencing with Section 7000)of Division Jof the
4 o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE y r
(C m the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR.
a3 - 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(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEV ICE 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 ProfessionsDRAINS-FLOOR,ROOF,AREA,CON D. 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-
mentsarenutintendedorofferedforsale.it,however,the budding GAS-EA.SYSTEM-l1NC.4OUTLETS 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 im- GAS-EA.SYSTEM OVER 4 IEA.) 2.00 BUILDING USE
prove for purpose ofsale.). RES IND CON PB Other
Cl 1,as owner of the property,am exclusively conimcting with INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project(Sec. 7044,BusinessLAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
0 El 0 El 11
and Professions Code:The Contractors License Law does not apply
to an owner of property who builds or improves Ihercon.and who LAWN SPRINKLERS-OVER1.00
contracts forsuch projects with a contructo4s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.0 TRACT NO. PARCEL NO.
❑ Iain exempt under Sec. ,B.&P.C.for this WATER HEATER W/VE
reason'
Owner Date WATER SYSTEM W5.00 ACC.DATE ACC.FILE NO.
WORK F-RS'COMPENSATION DECLARATION WA QUI
I'hemby at firm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy there
Policy N npany-deal
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T44
Z ,�'Ce d co y s filed ilh the I y .......tion division.
F p Applica l �.�1.. -f AI MISG- REFER TO ORD, v N� v N�
cc CF-RTIFIC,iTI�EMPTIONFFRRO�M�wORKERS' PERMIT ISSUANCE 10.0010 FL000 ZONE A.L.u.c.
W COMPENSATION INSURANCE G.C NTH LIC.NO.
D' O (This section need not be completed if the permit is for one �Q TOTAL �J v N Y N�
Z hundred dollars(SIO()or less.)
U O 1 certify that in the performance of life work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers Compensation laws of California.
to I] y Date Applicum ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT': If,after nm king this Cenificazc of lix-
F Z emption,you should become subject to the Workers'Compensation i APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with I
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1 FEE
F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(O C-FM,) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH D 5.00
the performance of the work for which this permit is issued fSec' MICROFILM
3097.Civ.C.). HEATING UNIT( 0 .U.) 8.00
Lenders Name
Lender's Address H EATI N G U N IT(OV ER 100 .50 ELECTRIC •-) y -�_-
I eerily that I have read this application and state that the above f VENTILATIO FAN4.00 --
information is correct.I agree to comply with all city and county gO1LER- .P,or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws relating to building construction, and
hereby authorize representatives of this city to enter upon the B -C (Ove 1 0 T S E FEE SCH. /c� rN
above mentioned property for inspection purposes. MECHANICAL /
(We) agree to save, indemnify and keep harmless the City of 1�915C.- RTO ORD.
Cupertino a '' st liabil'its,judgments, costs and expenses which CONST.TAX
I 'r any y accr a against said City in Consequence of the PERMI SSU E 10.00 /Q -
ranfi goft i. permit. MECH.CONT. LIC. MECH.
�Owt� 3�9D9 TOTAL /� - TOTAL
'go lureo Appi- Lorton,f r Date
OFFICE COPY