12439 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING / APPLICATION & PERMIT
aooREss / 0.10 1 /' BUILDING —ELECTRICAL—PLUMBING—MECHANICAL 12439
OWNER'S (i - PLAN CHECK VALIDATION
NAME _— ;t/A/ OTY. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
L1,.,Wt16gyqq 9LIGHTING FIXTURES 10.00/1.00 O
CONTRACTORS I APPLIANCES-RESIDENTIAL 4.00
AvyD,RESS a /,',q /yet /_�11[
a�W/090�Vf 1* PHONE O-V�J PANELS '10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
uc.No. ISIGNS TRANS.' - 3.00
ADD'Ess ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zip TEMP.METER OR POLE INS. PAM
AAPPLICADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 2110
uOFs o o LICENSED CONTRACTORS DECLARATION
<u E, I hereby affirm(hal 1 am licensed under provisions of Chapter 9 (,�„t_f- L I ISSUANCE DATE
<w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F 0 i Professions Code an in license is in full fort v it e efjya/L ❑
i
c c Licen Class -_Lic.Number -JS-��� ❑ ❑
r w Dale`1 trz, frl Contractor _
a xw BUILDING PERMIT
M Ic u OWNER-BUILDERDECLARA'EION INFORMATION
WI hereby affirm that I am exempt from the Conlrocto'r's Livens. MISC.— REFER TO ORD /
H .. 00J law forthe followingreason.(Sec.7031.5,Bmane.eand Professions PERMIT ISSUANCE 10.00 U a.
VALUATION $/FT.
,A Code:Any city or county which requires permit to construct,alter,
a x Q G improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
D s requires the applicant for such permit to file a signed statement that - TOTAL PERMIT TO
u w$ w he is licensed pursuant to the provisions of the Contractor's License
Fz ) Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
E c Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
W s-$ the basis for the alleged exemption.Any violation Of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of no(more than five hundred dollars($500)):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole,compensa(ion,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Caere:The Contractor's License Law does not apply to an owner of
properly 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- GAS-EA.SVSTEM-1 6.00
ments are not intended or offered for sale.If,however,the budding
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
build.,will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). .RES IND . 'CON PB Other
❑ d as owner of the property,he exclusively contracting with
INDUSTRIAL WASTE INTER. 30,00 ❑ ❑ El ❑ ❑
licensed contractors to . r( the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The who
Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPR
INKLERS-OVER 5(EA.) 1.00 ,
contracts forsuch projects with a contractors)licensed pursuant to SEWER-SANITAR YSTORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ l am exempt under Sec.—.B.&P.C.for Ibis WATER HEATER W/VENT 6.00
reason
Owner 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 of consent to self-insure,
or a certificate of.Workers Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). ww
Policy No. Com any uG i�- �f. NJJ
O. ❑ Certified copy is l).a an furnished FIRESPRINK ENERCYT-24
Z Z ❑ Certified wpy L tiled,with a�CW&inspection svisian
"���y�/ APDlicant _jjrr}}�1 MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
2 CERTIFICATE OF EXEMPTIONFROM WORE:.R PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W �_ COMPENSATION INSURANCE: PLG.CONTR. LIC.NO. PLG.
1 O This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z) Z hundred dollars(S 100)or less,)
U O 1 certify that in the performance of the work for which this per, OTY MECHANICAL PERMIT FEE FEE SUMMARY
IL F mil is issued,1 shall not employ any person id any manner so as to
U become subject to the Workers'Compensation Laws of California.
i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
z emplicn,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 permit shall be deemed revoked AIR HANDLING UNIT(TO 1QOODC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that (here is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ,C.).
Lender's Name
Lender's Address HEATING UNIT(OV ER 100,000 B.T.U.)9,50 ELECTRIC �dTU
I 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 Cry 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 representatives of this city to enter upon the BOILER-COMP (Over 100,00013TU)SEE FEESCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against babililies,i it en ts, costs and expenses which - CONST.TAX
may in any way accrue;against City in consequence of the PERMIT ISSUANCE 10.00
granting of this l'rmlt. MECH.CONT. LIC.NO. TOTAL
. 215 d ^-{2--P� TOTAL
Yfgaloure A ¢ant Contractor Date
OFFICE COPY