12279 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
'BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
PJI DRESS APPLICATION & PERMIT 12279
OaesS(��\� u1Y� BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
• O NER'S PLAN CHECK VALIDATION
.X NAME/ ` QTV. ELECTRIC PERMIT FEE
L�/`�E.
-1� { PHONE
CONTRACTORS
7LOUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
VOCR-P 2t SL's I C.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S >�h5� PPLI ANCES-RESIDENTIAL 4.00
A DEPRESS Ems,
�' r I WSL�PHONE r Z- F L PANELS 10.00 DATE OF APPLICATION
ARCHITECT
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.no. SIGNS TRANS. 3.00
.OR ENG. 5.00 PERMIT VALIDATION
ARCH
ADDRESS SPECIAL CIRCUIT
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. �I
ADDRESS
SERVICE CHANGE 20.00
see+O o LICENSED CONTRACTORS DECLARATION l
a I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F 'w Professions Cod 4 y license is in full force f t. ❑ ❑ ❑
z O License Class _ J Lic.Numbe
Q Date Contractor,
a xf BUILDING PERMIT
e w ¢ OWNER-BUILDER DECLARATION INFORMATION
O REFER TO ORD
3 u w I hereby affirm that I am exempt from the contractor's License MISC.- VALUATION S/FT.
F .. 0 a Law for the following reason.fSec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter' LIC.NO.
EE ra Q Q Improve,demolish,or repair any structure,prior to Its issuance,also ELEC.CONTR. ELEC.
o e requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m" he is licensed pursumri to tire provisions of the Contrnctur's License
Law(Chapter9(commencingwit),Section7000)ofDivision3oflhc
4 o Business and Professions Code)or that he is exempt therefrom and QTV, PLUMSTORIES TYPE CONSTR.
BING PERMIT FEE
e es fire basis for the alleged exemption.Any violation ol'Section 7031.5
n ; °�' by any applicant forapennit subjects the applicant macivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than live hundred dollars(5500).)'.
❑ 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,AREA,COND. 5.00
Code:The Contractors 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 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
merits 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 BUILDING USE
holder will have the burden of proving that he did not build or all- RES IND CON PB Other
prove RIF purpose of Sala). INDUSTRIAL WASTE INTER. 30.00
❑ 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 Contractors License Law does not apply
to as owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conUactorf sl licensed pursuant to
SEWER-SANITAR V-STORM EA.2001t/10.00 TRACT No. PARCEL NO,
the Contractor's License Law.
❑ 1 am exempt under Sec. .B.&P.C.for this WATER HEATER W/V ENT 6.00
reason
Ovv= Dale WATER SYSTEM 5.00ACC.DATE ACG FILE NO,
WORKERS'COMPENSA'I'ION DFCLARA'IION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofeansent to self-insure, ZONING ENG.SITE NO.
or u certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lab.C. .
Policy No. Colnpany �^�' 1SYaCaMPY.�
0 ❑ Certified co ¢h ehy l'umished. FIRESPRINK ENERGY T 24
Z- ❑ Certified 1 wi h e s inspection division. MISC.- REFER TO ORD. Y� IN Y � No
Applicant
by PERMIT ISSUANCE 10.00 FLOOD ZONE A,L.u.c.
ir - CIiRI'1 PIC. OP EXIiM ION PROM WORKIiRS'
DJ >_ OMPENSAI'ION INSURANCE PLG.CONTR. LIC.NO, PLG. Y❑ NE] V � N�
CL 0 (This section need not be completed it lire permit is 1'o1 one TOTAL
::) Z hundred dollars(S 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 P mit is issued,I shall not employ any person in any manner so us to
0 become subject to the Workers'Compensatiun Lawsof California. BUILDING
0pp �U
Uide Applicant ALTER OR ADD TO MECH. 5.00 0� �-
} N NOTICE*1'0 APPLICANT: If,after making this Certificate of Ex-
F Z emption,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 10=11F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE 3�
I hereby affirm that there is a construction lending agency forPEHAST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. G UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.0).
Lender's Name G HOOD
100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
-
V
certify that I have read this application and state that the aboveLATION FAN (SINGLE) 4.00
information is correct.I agree to Comply with all city and county -COMP(3 H.P.or 100,000 B.T.U.) 6.00PLUMBING
ordinances and state laws relating to building construction, andhereby authorize representatives of this city to enter upon theR-COMP(Over 100,°00 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection Purpo(We) agree to save, indemnify and keep harmless te City of REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of theT ISSUANCE 10.00tinhismit. LIC.N0. MECH.
X
To TOTAL
Sigmatur Ap 0cant/Cordrac Dale
OFFICE COPY