3212 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI.- POINT PEN ONLY
` BU I LDING PROJECT IDENTIFICATION P RMI BER
X OUILOING APPLICATION & PERMIT
A ORES$
all 0(M°f-SC7nVIKVAI.E 90 BUILDING- ELECTRICAL-PLUMBING-MECHANICAL 3212
OWNER'S f _ "'1 rf-rf `8,{ �"Ir ,iY'ry G-Y'n,' PLAN CHECK VALIDATION
NAME LLgg��yy��//�� •�� �j ( OTY. ` s ELECTRIC PERMIT (, "" y;i}r�t ''.FEE".
.,. STTI1111 PHONE OV �Ja- O ., n.w'I-,fN1 .1 dm4'G.
ON
NAME TRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTORSPPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT6.00 PLAN CHECK FEE P.C.NO.
OR SIGNS
ENGINEER 3.06
LIC.No. SIGNS TRANS.
ARCH.OR ENG. 5.66 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER 08 POLE INS. 15.00
APPLICANT'S
AGGRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 3/y/6�
w
Do LICENSED CONTRACTORS DECLARATION / O
< 0 U 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
N<w (commencing with Section 7000)of Division 3 of the Business and el _ T. PLG. MECH.
HN i Professions Code,and my license is in full force and effect. El ❑ fL�
0 v+c License Class Lic.Number ]L
,a I-w Date Contractor
w¢ a; OWNER-BUILDER DECLARATION IN ETON. g1-xs
':f'r- ;INFORMATIONS pi'L
u N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD yysx�� y Ifws9�{pp1 S/FT.
a-01 Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.06 i4 Vfsnsl+m Lino
Code:Any city or county which requires a permit to construct,alter.
2 Q 40 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. Q
O LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO eP�,e
m$ he is licensed pursuant to the provisions of the Contractor's License - ..
F z<
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe "4•'fr n;.. •• 'PLUMBING PERMIT G' 'c`7
s 4 D. Bminess and Profeaions Code)or that he is exempt therefrom and OTV It` v' T"v P •' `} FEE"
•y�
¢1- � the basis for the alleged exemption.Any violation of Section 7031 5 ,{?d. r r R- _o-R. .a 91"•n r'�':''l T ,i'.'!h_ .e Tr!"�"-i:a STORIES TYPE CONSTR.
a, by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4,00
of not more than five hundred dollars(5500).1:
O 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 2.00 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. 4.00
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 4.00 SMOT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments an not intended or offered for Sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4,00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im. RES IND CON PB Our.,
p`;e for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
7` I;as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors t0 construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 - 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/8.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
13I am exempt under Sec.-.B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date I or,a s Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affinn that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workeri Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.l.
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24 !
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. Y N v N
O Applicant ❑ ❑ ❑ ❑
2H CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG,CONTR. LIC.NO. PLG
CL . Y❑ N❑ Y❑ N❑
O (This section need not be completed if the permit is for one TOTAL
� Z :hundred dollar,(S 100)or lem.l "
U O 1 certify that in the performance of the work for which this per ix r. - PERMIT:' ^ .FEE SUMMARY� r`"i''
U 8- mit is issued,I shall not employ an, person in any manner so as to OTY.'`. MECHANICAL . FEE1 `
U become subject to the Workers'Compensation Laws of California.
CL Date Applicant ALTER 08 ADD TO MECH. 4.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
I.. ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 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=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CY.C.). HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Addre H EATI NG UN IT I OV ER 100,000 B.T.U.)7.50 ELECTRIC
ss
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00 Gg,9
-� information is correct I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.or/00,000 B.T.U.1 4.00
hereby authorize representatives of this city to enter upon the BOI LER-COMP (Ova,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 which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
RmNing of this em" MECH.MECH.CONT. LIC.NO. MECH
TOTAL
. -
(lE as,
i pp�a3.lty /torch 7i IfB� TOTAL(`,
nature of Apphon
ct/Contractor Uate I '
OFFICE COPY