12473APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON
APPLICATION & PERMIT
BUILDING -ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
12473
BUILDING . 119.6 I�6' U, �v
ADDRESS.
_ ,SD�
�
NAME JrTG•� J, /9YlIOC"�/_Cl_� I
PNONE ZS,y
Q. 7X ELECTRIC PERMIT FEE
'v
PLAN CHECK VALIDATION
'
CONTRACTORS
NAME
10 OUTLETS -SWITCHES -RECEP 10.00/1.00 O-
LIGHTING FIXTURES 10.00/1.00 O
CC. NO.
CONTRACTORS
A DORE55
APPLIANCES RESIDENTIAL 4.00
PANELS 10.00
PHONE -
DATE OF APPLICATION
ARCHITECT
OR
O
ENGINEEfl
LIC. NO.
PANELS (OVER 200 AMIN 20.00
PLAN CHECK FEE .P.C. NO.
ISIGNS TRANS. 3.00
ARCH. OR ENG.
ADDRESS
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
,
IIP
EMP. METER OR POLE INS. 20.00
A
ADDDRDREESSSS
MOTORS FIv12 O �• SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
yJ
1 hereby afr. that I am licensed under provisions Of Chopter 9
(commencing with Section 7000) of Division 3 of the Business and
PrOfeSs10n5 Code, and my license IS In full force and effect
Class Lie. Number
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
ElLicense
UateContractor
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
I herebym affuthat I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand Professions
Cady: Any city orcounty which requiresa permit toconstruct,.iter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for Such permit to file a signed statement that
he Is licensed pursuant t0 the provisions of the Contractors License
Law (Chapter 9 (commencing with Section 7000) of Division 3nfthe
Business and Professions Code) or that he is exempt therefrom and
MISC. - REFER TO ORD
PERMIT ISSUANCE' 10.00 U
VALUATION
ELEC. CONTR. LIC. ND. ELEC.
TOTAL. J
OTY. PLUMBING PERMIT FEE
PERMIT TO
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (4500).):
STORIES
TYPE CONSTR.
ALTER -DRAIN -WATER IEA.), 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
'
Code: The Contractor's License Law does not apply to mI owner of
FIXTURES - PER TRAP 5.00
SO. FT .FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who does such walk
himself or through his own employees, provided that such improve-
mentsare not intended oroffered for sale. If, however, the building
_ GAS-EA.SYSTEM-1 INC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did. not build or im-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
- .
GAS EASYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Other
I N DUSTR I A L WASTE INTER. 30.00
SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
licensed contractors to construct the project (See 7044, BusinessLAWN
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
ASSESSORS PARCEL NO.
contracts for such projects with a contractor( s) licensed pursuant to
the Contractors License L.W.
Cl larp,exemp a dor Sec ,B.&I'.C. for Geis
anon i
SEWER-SANITAR V -STORM EA. 200ft/10.00
TRACT NO,
PARCEL NO.
WATER HEATER W/VENT 6.00
caner Dt 3•e�-
WATER SYSTEM 5.00
ACC.OATE
ACC. FILE N0,
WATER TREATING EQUIP. 5.00
WORK Ii RS' COMPENSATION DECLARATION
1 hereby affirnn that I have a certificate of consent to sell' -insure,
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof (Sec. 3800, Lab.C.).
ZONING
ENG. SITE NO.
Policy No. Company
❑ Certified ropy is hereby furnished.
❑ Certified copy is fled with the city inspection division.
Applieanl
FIRE SPRINK
Y[] No
ENERGY T 24
Y❑ N�
MISC.- REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
PLG. CONTR. LIC. NO.
PLG.
TOTAL
Y ❑ N
Y El NF]
hundred dollars (S100) or ILEO
1 certify that in the perfor ante of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY -
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00
AIR HANDLING UNIT (TO 110MC.F.M.) 4.00
PLAN CHECK
FEE'
enhption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (OVER 10A000.EM.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
H EATI N G U N IT IOV ER 100,000 B.T.U.) 9.50
ELECTRIC
1 certify that I have read this application and state that the Shove
VENTILATION FAN (SINGLE) 4,00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
g01LER•CQMPI3 H.P. Df 100,000 B.T.U.) 6.00
LER-COMP (Over ) SEE FEE SCH.
801 000 BTU) U
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, j udgments, costs and expenses which
may in any way aecrue,a ins sand City in ..sequence of the
granting of this 'onl
Contractor
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIC. NO. MECH.'
TOTAL.
TOTAL
Signature ofAr n:/ Date
OFFICE COPY