12587 AaPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
7- ADOnas� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 12587
Owry 'aPLAN CHECK VALIDATION
NAM OTY. ELECTRIC PERMIT FEE
vuoN
R
NA
ry TRACTO s OUTLETS-SWITCHES-RECEP 10.00/1.00
•� / q/
LIc.N0,7 -ttt�N/ LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S d77Ig1� APPLIANCES-RESIDENTIAL 4.00
'ADDRESS
vee PANELS 10.CO PATE OF APPLICATION
OR
HITECT - PANELS (OVER 200 AMP) -20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.NO, SIGNS TRANS. 3. 0
ARCA"Ess ENG" SPECIAL CIRCUIT PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 I
APPLI MOTORS E �(J
ADDRDDRESSSS ",`
SERVICE CHANGE 20.00 610
w o o LICENSED CONTRACTORS DECLARATION
< u I hereby affirm that I am licensed under provisions of Chapter 9 7 xs e -f- ( ISSUANCE GATE
Naw (commencing with Section 7000)of Division 3 of lite Business eW
BLDG. ELECT. PLG. MECH.
r w i Professions C��ode,a�QQd my lice s hs m full f ah effrvct ❑ ❑
o i w,W License C asa -n tt� .Numb-_ o-,t/n /
Date Cmnq acro
Q y J qq��f
¢ ¢ a OWNIi R-BUILDER DECLARA41V�14SBUILDING PERMIT
o e- u INFORMATION
X g r I hereby affirm that I on exempt Crom the COm nmtor'r License MISC.- REFER TO ORD
w VALUATION
w w J Law for the following reason.(Sec.7031.5,Business and Professions 10.00 (/ -
Code: e,dem y demolish,
countypair any structure p prior
it o Consuance,aeq
PERMIT ISSUANCE
5 2 a Q improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
w g G LL requires the applicant for such Permit to file a signed statement that TOTAL ( -
X
PERMIT TO
$ he is licensed Pursuant to the provisions of the Contractor's License
r z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the G
2 i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT. FEE '
¢ r o the basis for the alleged exemption.Any violation of Section7031.5 -
STORIES TYPE CONSTR.
L.A. m by any applicant for a permit subjects the applicantapplicantto a civil penalty
of not morere than five hundred dollars($500).). ALTER-DRAIN&VENT-WATER (EA.) 5.00
O 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
• properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP. 5.00 SO.FT,FLOOR AREA TOTALACREAGE
himself'Or through his own employees,provided that such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GA$ EASYSTEM OVER 4(EA ) 2.00
builder will have the burden of proving that he did not build or im • . - .
BUILDING USE
prove for purpose ofsaleJ. INDUSTRIAL WASTE INT 30.00 RES -IND CON Pa other
El 1,as owner of the property,am exclusively contracting with El 11 ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. r O ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS- 5 E ) 0
contracts for such projects with a contractor(s)licensed Pursuant to
the Contractor's License Law. SEWER-SANITARY-ST EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exemptunder5ec. ,U.&RC.for this WATER HEATER W/VEN CQ
reason
.Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsenl to self-insure,
or a certificate of Workers'Comp{{•.q�hsal iqqn� Insdyfance,ora certified! ZONING ENG.SITE NO.
copy Ihnreof(Sec.3800,Lab.CJ.JTNt8(Yea' OMP en88t1 n
Policy N ri=*hnrRmy ;r&q _
z ❑ Certi YYNs filed fvoth t uYaIICe-Funzi FIRE SPRINK ENERGYT20
Z ❑ anrtified copy is filed with the city inspection division. MISC.- REFER TO ORD.
Q Applicant y E] ry� y El ryC3
W C17RTIFICA'fl'OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 ,0 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANC17 PLG.CONTR. LIC.NO. PLG. /
d O (This section need not be completed if the penrit is for one TOTAL /b Y❑ N❑ Y [:) N
::) Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to -Ti
O W become subject to the Workers'Compensation Laws of California.
n Date - Applicant BUILDING
} y NOTICE TO APPLICANT: If,after making this Certil'icule of fix- ALTER OR ADD TO MECH. 5.00
F Z emption,you should became 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 HANDLIN NIT(TO 10000 .M,) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING U IT(OVER 10 DFM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD ITHOCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TON ,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(O 00,000 B.T.U.)9.50
Lender's Address ELECTRIC JJ
I certify that 1 have read this application and state that the above VENTILATION F NASILE) 4.00
information is correct. I agree to comply with all city xnd county PLUMBING 6.
ordinances and state laws relating to building construction, and BOILER-COMP(IH.P.or 100, OB.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BT $EE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. 7d 0-a
(We) agree to use, 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 an way aceta again City in consequence of the O
".Ung is permit 'MECH.CONT. LIC.NO. MECH.
�7 TOTAL - TOTAL 31C4�OF
o Applicant/Co tr or Date
OFFICE COPY
r