12236 • ' APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 12236
AooRESs
53 A 1G A • BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS " - PLAN CHECK VALIDATION
"AME _ QTY. ELECTRIC PERMIT FEE`
_MIM
PHONE
CONTRACTORS
NME
EF OUTLETS-SWITCHES-RE 00
10.00/1.LIGHTING FIXTURES 00
-
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00 Q
ADDRESS
C' -PHONE R PANELS 10.00 DATE OF APPLICATION
ARCHITECT 1.j I)kA Tj� � PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR J
ENGINEER t
uc.No. SIGNS TRANS. 3.00
ARCH MEN'. - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
21p TEMP.METER OR POLE INS. 20.00
ADDRESS
v
APPucnrvrs. - MOTORS `SEE.FEE SCH.
'
SERVICE CHANGE 20.00 �1
w o g LICENSED CONTRACTORS DECLARATION (x C (/1/ l
<v w I herebyaffirm that I am licensed under provisions of Chapter 9
' P P ISS ANCEDATE
a,G (commencing with Section 7000)of Division 3 of the Business and V - BLDG. E EC PLG. MECH.
f, y i Professions Codeode and_% Liis in full fDapd e �.y iixl f p ❑ ❑ ❑
Z o m - License Cloffs Lic.Numb 41
o m 1-w Date174_ Contractor
¢ Y 2 I-- BUILDING PERMIT
¢ ¢w¢ OWNER-BUILDER DECLARATION
e A U INFORMATION
K
; LL N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
ua. Law forthe following reason.(See.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION 5/FT.
F wCode:Any city or county which requires permit to construct,alter, .---
4 improve,demolish,or repair any structure,prior to its issuance,also E EC.CONTR. LIC.NO. FEED. / O p'f1
0 u - requires the applicant for such permit to file a signed statement that �R� vE _�� TOTAL {Q RMIT TO
X$ he is licensed pursuant to the provisions of the Contraclor's License
H i i Law(Chapter 9(commencingwith Section 7000)ofDivision 3 ofthe
¢ Business and Professions Code)or that he isexempt therefrom and QTV. " PLUMBING PERMIT r FEE
re thebasisfor the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
e- by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(55000.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,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
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 TOTALACREAGE
himself or through his own employees,provided that such improve-
• mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
Or improvement is sold within one year of completion,the owne" GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im. BUILDING USE
RES IND CON PB other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
Cl 1,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. 6.00 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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'1'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofemisent to sell'-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,LAC.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed Willi the city inspection division.
O Applicant
MISC.- REFER TO ORD.
� Y ❑ N❑ V ❑ IN
V- y PERMIT ISSUANCE- 10.00
� CIiRTIPICCOEOF PENATIOIN INSURAMWORgERS• FLOOD ZONE A.L.u.C.
' W > COMPENSATION INSURANCE PLG.CONTR. LIC.N0. PLG.
CL Z( This section need not be completed if the permit is for one - TOTAL Y E] NE] Y ED INC]
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per. QTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is sued I shall not colo ry erson in un manner so as to
U beepppQQQIII ��yy IIBB yq�ca"1 Workers set sminn La s f C, ifornia
O i NOT#. F blICAN : I,�k ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOT#. f AI' LICAN'f: If,a along this Cc 1 licatc of Ex
♦- Z eolption,you should become subje t the Workers' tmperismion APPLIANCE 5.00 PLAN CHECK
p, visions of lire Labor Code, yo usl forthwith comply with FEE
U Such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION U:NDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 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 1 r which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
9097,Civ.CJ.
Lendcr S Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 6Q
Lender's Address - ELECTRIC
1 certify that I have read this application and slate tbm'the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives Porins of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
shove-mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may 'n any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gran[ filial permit. MECH.CONT. LIC.NO. MECH.
c6 TOTAL TOTAL
Signature pplicant/Contr or DAc '
OFFICE COPY - -