12353 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING - - - APPLICATION & PERMIT
ADDRESS :2 ^� l� 12353 '
e( Qd ��I BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S 1
PLAN CHECK VALIDATION
CIO
NAME t
_ QTY. ELECTRIC PERMIT FEE
-D0401.,S. " PRONE.
NAAMFRADToOs ,r OUTLETS-SWITCHES-RECEP 10,00/1.00
LIC No. ilfcg7St' LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S i,
DRESS c t/�yjpf.��'l'1Pio. APPLIANCES-RESIDENTIAL 4.00
•D• O S2� 9] PHGNE .25S�14 PANELS - - 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP)' 20.00
ENGINEER
ARCH.OR TIC,No. SIGNS TRANS. 3.00
ADDRESS ENG ' SPECIALCIRCUIT 5,00 - PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20,00
APPLICANT'S
ADDRESS MOTORSFEE SCH.
` SERVICE CHANGE EE -20.00
'02
Oo LICENSED CONTRACTORS DECLARATION ��
a v W I hereby affirm that 1 am licensed under provisions of Chapter 9 JAN 12 1901
Q w ISSUA CE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. 'ELECT. PLG. MECH.`
R Z Professions Code and my license is in full fom n effect. - ❑ ❑ ❑ ❑
p L 0 o License Clad C"Ie -Lic.Numbe�y Kfy FIB- III a Ul 1U
H w H j Date- Contractor _
¢ S,w a OWNER-BUILDER DECLARATION l �A•N9L BUILDING PERMIT
- o " INFORMATION
R:e N affirm X I hereby arm that 1 am exempt from the Contractor's License MISC.,- ER TO ORD
u o j Law for the following reason.(Sec.7031.5,Busineesand Professions - VALUATION $/FT.
- PERMIT ISSUANCE 10.00
i w)E Code A,demolish,
ty Dreamilywhichany requires eP rior ttoconstrvd,a her, '-'
X E 0 O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. �� U
A. requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
X
Crm w he is licensed pursuant m the provisions of the Contractor's License e
r z <
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe r C
f 4 O Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
X the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n 3- by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(S500))
ALTER-DRAIN&VENT-"ATER (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 structure is not 'OCC.GROUP REB.UNITS
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00 -
Code:The Contractor's License Law does not apply to an owner of
property who builds of improves thereon,and who does such work F IXTUR ES-PER,TRAP 5.00 SQ.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-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, - . - .
the owner- GAS EASYSTEM OVER 4(EA) 2.00
builder will have the burden of proving that he did no[build or im- BUILOING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00 RES IND CON PB Omer
.
❑ L as owner of the property,am exclusively contracting with �.
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.001:1
.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 contractor(s)licensed pursuangto
the Contractor's License Law. r SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 -ACC.DATE ACC.FILE NO.
WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm 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 thereof(Sec.3800,Lab.CJ. - -
Polley No. Company
O
1t❑ Certified copy is hereby furnished FIRE SPRINK ENERGY Tia
Z Z ❑ Certified copy is fled with the city inspection division. �J
p: O Applicant MISC. REFER TO ORD. YE] IN E] Y ❑ NE]
PERMIT ISSUANCE 10.00
LU > CF.RTI FICCOMPENSATION EXEMPTION PROM WORKERS' : FLDDD ZONE A.L.U.C.
a.1 , LG
(This section need nobcompleted INSURANCE theEpennit is for one PLG.CONTR. - LIC.NO. TOTAL V N Y N
ac
Z hundred dollars(S 100)or less.) 1
LL O I certify that h the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall'not employ an arson in any manner so as to
O w become b'ec to I WorK aRon L ws of Calif soca.
D. Date LICANT: I "'�� ALTER OR ADD TO MECH. 5.00 BUILDING -
} N NOTIC O A PLIGANT: If,a tel m; g us cr[ifical of Ex-
Z emptiun,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 10MC.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. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT 100,000 B.T.U.)9,50 `�..
Lender's Address 'ELECTRIC
1 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 BOILER-COMP(3'H.P.Or 100,000 B.T.U.) 6.001PLUMBING
ordinances and state laws relating to building construction, and -
hereby authorite.representatives of this city to enter upon the - t
above-mentioned property for inspection purposes, 1301 LER-COMP Over 100,000 BTU)SEE FEE SCH. 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 said City in consequence of the '
gra f otpi�spermy'�. MECH.CONT. LIC.NO. MECH.
"JA /b-'x 47 TOTAL TOTAL
Signature of Applicant/Contract Date
OFFICECOPV