12805 APPLICANT TO FILL IN INFO RATION WITHIN RED LINES - USE PALL POINT PEN ONLY
BUI LD1 NG PROJECT I DENTI FIC PERMIT NUMBER
•ADDRESS ��� APPLICATION & PEWIT
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12805
Owry ER's PLAN CHECK VALIDATION
,�"AME c CITY. ELECTRIC PERMIT FEE
I I F OJ PHONE
�\ CONTRACTOR'S
NAS. ��pp UTLETS-SWITCHES-RECEP 10.00/1.00
M
ta0(( V OM 1 �- LIc.No. LIGHTING FIXTURES 10.00/1.00
rONTRAC;O
OORESS PPLIANCES-RESIDENTIAL 4.00
3131 -
A
I)/ OBJ, ,PHONE / ' PANELS 10.00 DATE OF APPLICATION
OR PANELS
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIc.NO. SIGNS TRANS. 3,00'
AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS rs
A -
ADDRESS
MOTORS SEE FEE SC
SERVICE CHANGE 20.00 / /(
o o LICENSED CONTRACTORS DECLARATION W a
a v w I hereby affirm that I am licensed under provisions of ChSpter'I ISSU NCE DAT
y a `a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r w z . Professions Codc.�llJ my license is in full f-CA f_fe�M • ❑ ❑ ❑ ❑
oi a o License Cla�s �,5'I Lie.Number x] bS
y H w Da[C a $ Contractor t
2 0 If w u OWNER-BUILDER DECLARATION - BUILDING PERMIT
n D INFORMATION
'x ;0 I- I hreMISC.- REFER TO OR
eby dfRrm that I am exempt from the Contractor's License y
ce Law forthe followingreason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
fwve Code:Any city orcounty which requires a permit to construct,alter, G��
rt t[ Q O improve,demolish,or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.N0. ELEC.
wO u raluires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m he is licensed pursuant to the provisions of the Contrac(oi s License
Uzi Law(Chapter 9(commencingwith Section 7000)of Division 3 fthe
a: o
Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE /L' OL40
6r the basis for the alleged exemption.Any violation ol'Section7031.5 STORIES TYPE CONSTR,
ore
by any applicant for a permit subjects file applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(8500).):
❑ 1,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 Contractor's Lice rse Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTALACREAGE
imself or through his own employees,provided that such improve-
. rents are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner- �I
will have the burden of proving that he did not build or it. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
Prove for purpose of sale.). REB IND CON PB Other
ID 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ 0
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Codc: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 contractor(s)licensed pureuont to
the Contractor's
nosi c Law. SEWER-SANITARY-STORM EA.200ft/10.00
TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,IT&RC.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK 1iRS'COMPENSAIION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure,
or a certificate of Workers Compensation Insurance,or a cetlifrCd ZONING ENG.SITE NO.
copy therPPe.pf 1 3800,LahC.) �pp � -
Policy NoPComp:my_F�LPa�-SAD
O Q❑I Certifiedcopyisherebyfumished' FIRE SPRINK ENERGY T-Z4
Z Z p Certified copy is Bled with he ci insy"li ivision. MISC.- REFER TO ORD. Y
1--' A 7alicant - 3.� NEI V NF]-
CC
CC m CERTIFICATEOF EXEMPTION I7ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L COMPFNSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 0 This Action need not be completed if the permit is for one TOTAL Y[3 N Y [:] N
Z hundred dollars(8100)or Ices.)
L) O 1 certify that in the performance of the work for which this per CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL F unit is issued,I shall not employ any person in any manner So us to
U become subject to the Workers'Compensation Laws of Caldernin.
U-1 Dltic Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ to NOTICE '1'0 APPLICANT: If,after....king this Certificate of Ex-
F Z Cmption,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 decried revoked. AIR HANDLING UNIT(TO 10=1 .F.M.) 4.00
.CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMICFEE
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. MICROFILM
3097,Civ.C.), H EATING UN IT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATING LIN IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
/
all\ I certify that 1 have read this applicafion militate that file above VENTILATION FAN (SINGLE) 4.00 30
information is correctd agree to comply with all city and county PLUMBING
,saidir5nces and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP t0var 100,000 BTU)SEE FEE SCH. 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.1add, PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue again said Cif 'n consequence of the
GrantinEfApplu mit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signalcan ontrtor .0 a i1
OFFICE COPY -