12524 i LICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' / BUILDING PROJECT IDENTIFICA_ APPLICATION & PE T PERMITNUMBER
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�GBLll6L ) UILDING -ELECTRICAL-PLUMBING-MECHANICAL 12524
DINER'S _
PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
L -
Co ACTORSUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
Llc.no.l LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS T
A/6wvo o 5 PANELS 10,00 DATE OF APPLICATION
ARCHITECT
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE I P.C.NO.
OR
ENGINEER LIC,No, SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 6.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
aooe ss TS MOTORS SEE FEE SDH. �
SERVICE CHANGE 20.00 I� /&•�
0 IS z / I
Foo LICENSED CONTRACTORS DECLARATION
rt U. I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
n 4 y (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
F 0 z Professions C and4mIl license is in fall I'urS�,�IIT e ❑ ❑ �I
z O - License C as fG G-
Lie,NumberL%�
Q Y F Date Contractor
BUILDING PERMIT
2 w OWNER-BUILDER DECLARATION INFORMATION
w uw 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION $/FT.
LL o a Law for the following reason(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
- V,ICode:Any city m county which requires permit to construct,alter,
2 s- 20 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
C K requires the applicant for such permit to file a Signed statement that TOTAL PERMIT TO
a w m" he is licensed pursuant to the provisions o1'the Contractor's License ,x
H IS i Law(Chapter 9(commencing with Section 7000)of Division 3of(he �GB r, !L/,4ecl�
Business and Professions Code)or that he is exempt Omrefrom and QTY. PLUMBING PERMIT FEE
r es the basis for the alleged exemption.Any violation of Section 7031.5 p STORIES TYPE CONSTR.
i ;O1 by any applicant for a permit subjects the applicantlo a civil Penalty gLTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as IBACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for Sale (Sec. 1044, Business and Professions DRAINS-FLOOR, EA,COND. 5.00
Code:The Comractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work IXTUR ES-PER AP ��� 5.00 SD.FT,FLOOR AREA TOTAL ACREAGE
marts are not hrough
own empldYorSle.If,ed that however,
improve- GAS-EA.SYSTEM-e INC.40UTLET$ fi.00
monis are not intended or offered for solo.If,howeveq the building
or improvement is sold within one year of completion,the owner- v
buildu will have the burden of proving that he did not build or im- GAS-EA.SV STE,ryh-OV ER 4 IE Q 2.00 BUILDING USE
RES IND eOry vB Omer
prove for purpose of sale.). INDUSTRIAL WASTEI 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLE -)1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Low 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 al Contractor(S)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ lam exempt under Sec..,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 7-TCC DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofcoment to self-Insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a-certtiifiied
copy thereof(Sec.3800,Lab.C.I F A/D �A:I
Policy No. Compnny_f�Vl�!P
Q ❑ Certified copy is hereby furnishe�f FIFE SPRINK ENERGY Tg4
Z Z L-4 CertiOusyupY is Eed,srith Ativ city inspection division. MISC.- REFER TO ORD. y ❑ ry❑ V ❑ N❑
O Ap iiclml=e da -- UUU
N CER'TIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 �i! FLOOD ZONE A.L.U.C.
W >_ COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. 0
dQ TOTAL 3C V❑ N❑ Y ❑ N❑
('This section need not be completed if the permit is for one
:) Z hundred dollar,($100)or lass.)
U O I certify that in the performance of Ole work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
IL P mit is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH 5.00 20
} ti NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? onplion,you should become subject it)the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of ilia Labor Code, you must forthwith comply Willi -a FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10 CF.:M.1 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.F.M.) 6.00 - SEISMIC FEE
I hereby affirm that there is a construction lending agency for XHAUST HOOD(@LITH DUC ) Q, •00 .f MICROFILM
the performance of the work for wh/ic�hh this permit is issued(Sec. HEATING UNIT(TO 1 P. ErT,U.) 8.00
3097,Civ.C.). �i/IT/7L .0-qu//� C. O
Lender's Name HEATING UNIT(OV ER100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and stale that ilio above VENTILATION FAN (SINGLE) 4.00 3o/
information is correct. 1 agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating hl building construction. and
hereby authorise representatives of this city to colter upon the BOILER-COMP (Over 100,000BTU)SE FEESCH. MECHANICAL �✓
above-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 PERMIT ISSUANCE 10.00 U CONST.TAX
may in any way Pierue against mid City in a To, Ten qV the
granting Of this germy. / MECH.CONT. LIC.NO. MECH.
/�jfornn�oR� Ci.�a /1�/ 3I ��
TOTAL -3 TOTAL
Signature of Applicant/Contractor D,ue
OFFICE COPY