11252 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
ADILOING APPLICATION & PERMIT 11252
Ao ILDIN
0
BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S
AME
PLAN CHECK VALIDATION
• DTV- ELECTRIC PERMIT FEE
.. PHONE SL
CONTRACTOR,
rvamE UTLETS-SWITCHES-RECEP 10.00/1.00
LIc.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S -
ADDRESS —APPLIANCES-RESIDENTIAL 4.00 '
PHONE PANELS - .10.00 DATE OF APPLICATION
ARCHITECT CHECK FEE P.O.NO.
DR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ARENG. PERMIT VALIDATION
ADDRESS
Ess SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.011
a¢i
r O o LICENSED CONTRACTORS DECLARATION -
i'W I hereby affirm that I am licensed under provisions of Chapter 9
W
¢ n (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
r 4 i Professions fessns Code,and my license is in full force and effect BLDG. ELECT. PLG. MECH.
2 z n License Class oNumber ❑ ❑ ^ ❑
,A H Dale Cn_ Contractor {LY
¢ x s J BUILDING PERMIT
¢ o n OWNER-BUILDER t from RATION INFORMATION
X ; w I hereby affirm that I am exempt from the Contractor's License MISC.—' REFER TO ORD
u o¢ Law for the following reason.(Sec.]031.5,Business and Professions VALUATION $/FT.
� — Code:Any City or county which requires a permit to construcq alteq PERMIT ISSUANCE 10.00
QQ ¢o Improve,demolish,Or r`palr any]'fracture,Perot to IlS ISSUJOCE,aIs. ELEC.CONTR, LIC.NO.
o u requires the zpplican,Ibr such permit to file a signed sf ulemcnt that TOTAL
app
A w m he i5 lEL
icensed pursuant f0 the provisions Of the Co.,
i Licenu PERMIT TO
H z a Law(Ctopic 9(com-.he-,with Section 7000)of Division3of the
i o Business and Professions Code)or that he Rexempt therefrom and OTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 703 LS STORIES TYPE CONSTR.
i3 byanyrozztant forapennv subjects the applicant toacivil penally ALTER-DRAIN of not more than five hundred dollars(3500).): (EA.) 5.00
❑ I,m owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
than 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 docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
menlsare no(intended or offered for Sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement is Sold within one year of completion,the owner
builder will have the burden of proving that lie did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00BUILDING USE
prove for purpose of the.). INDUSTRIAL WASTE INTER. 30.00 RES IND� ❑ ❑N ❑ Other❑
❑ I,as owner of the property,em exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
and Professions Code:The Contractor's License Law does not apply ASSESSORS PARCEL NO.
to an owner of property who builds or,improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1,00
contracts for such projectt with a contractor(s)licensed pursuant to
the Con tractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/ NIT 6.00
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
WORKERS'COMPE SATIONDL'CLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG-$ITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished.
Z 2 ❑ Certified copy is filed with the city inspection division. FIRE SPRINK ENERGY T24
F O Applicant MISC.- REF R Y C] NF-1 Y C] N[:3 _
DC y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE r< 6.00pp FLOOD ZONE A.L.u.C.
W > (This section neednON TINSURANCEION
beCompleled if the permit is for one PLG.CONTR. LIC.NO. TOTAL O`V �` Y N v ry�
n. o
� Z hundred dollars(81001 or less.)
0 O I certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner So as to
become subject to the Workers'Compensation Laws of California.
0 y Uate Applicant ALTER Ofl ADD TO MECH. 5,00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must'forthwith Comply with FEE
(.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIRHAND LINGUNIT IOVER10=C.EM,) 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. MICROFILM
3097,CR.C.). HEATING UNIT(TO 100,000 B.T.U.) B.00
Lenders Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that 1 have read this application and state that the above' VENTILATION FAN (SINGLE) 4.00
information is correct. I agree m comply with all city and county PLUMBING O
ordinances and state laws relating to building Construction, and BOILER-DOW 13 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over[00,000 BTUI SEE FEE$CH. MECHANICAL
(We) agree to save,'indemnify mrd 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 i nsequence o!the PERMIT ISSUANCE 10.00
grantingofthls permit. MECH.CONT, LIC.NO. MECH.
_116,_ - TOTAL TOTAL
Signature fApplicant/Co ractor Date
OFFICE COPY