12464 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES r USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
ADDR SS APPLICATION & PERMIT 12464
a/// ! BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
/ � 7L "
/ OWNER'S PLAN CHECK VALIDATION
NAME
V"n D ,A A,' PHONE DTV. ELECTRIC PERMIT FEE
CONTRACTOR'S P 0.0011.00
NAME 666 �s�p•U rA,1T OUTLETS-SWITCHES- 1
Lhj1'LOII'/C VD'L'6r"z�
LIC. o14 3-23 LIGHTING FIXTURES 10.00/1.00 Is
CONTRACTOR�s
ADDRESS
�- PPLIANCES-RESIDENTIAL 4.00
Ap ,V
4837 'p PHONE 353-31y PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.01) PLAN CHECK FEE P.C.NO.
OR
ENGINEEfl'
LIC.NO SIGNS TRANS. 3.00
neo'Ess END' SPECIALCIRCUIT - 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 -
APPLICANT
ADDRESS - MOTORS SEE FEE SCH. �
SERVICE CHANGE 20.00 - ���•�/$ '�
o o LICENSED CONTRACTORS DECLARATION - �/ G
¢ u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N<n (commencing with Section 7000)of Division 3 of the Business BLDG. ELECT. PLG. MECH.
H o i Professions Code, my license is in full fort + e L
z o On- License lass Lia Number. 0
o H G Date- - Contractor
H - Q
¢ w¢ OWNER-BUILDI-V DECLAR 1' BUILDING PERMIT
v INFORMATION
E:
a H I hereby affirm that I am exempt from the Contractor's Llcefise MISC.- RD
FLL00j Law for the following "son.(Sec.7031.5,Business and Professions PERMIT ISSUANCE \ 10.00 - VALUATION 8/FT.
i
Code:Any city or county which requires a permit to construct,alter,
¢ ¢ ¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. _q
wmIE requires the applicant for such permit(o file a signed statement that TOTAL [TV PERMIT TO
he is licensed pdrsuanl to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
1i c Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢I-$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ; - by any applicant for a pemdt subjects the applicant tea civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(SS00)J:
O I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business,and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's LICCn.0 Law does not apply to an owner of
property who builds or improves Ihamon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT,FLOOR AREA TOTAL ACREAGE
himself m through his own employees.provided that such improve
meats are not through
or employees,ffered for provided
e. ed thatlI.wcvsuhebuilding GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that be did not build or im
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PS Ome,
IDI,as owner of the properly,am exclusively contracting with El ❑ 11 D
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 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 forsuch projectswith a conlraetods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA,200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM - 5.00 ACC.DATE ACC.FILE NO.
WORK F.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsenl to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.) �N
Policy No Company `
❑ rtifie Co yis hemby urn d. FIRE SPRINK ENERGY T-24
Z 2 ertil" d py is flet vei the ity inspection division.
ph Appli ant MISC.- REFER.TO ORD. Yo N❑ v 0 NE]
~ vaPERMIT ISSUANCE 10.00
IF ' l
ICATE OI'1i PTION FROM WORKERS' FLOOD ZONE A.L.U.C.
L COMPENAVON INSURANCE PLG.CONTR. _ LIC.NO. PLG.
Z (This section need notompleted if the permit is for one TOTaL Y N v No
hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
L U mit is issued,I shall not employ any person in any Canner so as to
become subject to the Workers'Compensation Laws of California.
y Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z eruption,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=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MIC.F.M.) 6.00 SEISMIC FEE.
I hereby affirm that (here 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.L ` HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT 100,000 B.T.U.)9.50 �Q 00
Lender's Address ELECTRIC
I1'N 1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4,00
'k information is Correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
�\ above-mentioned property for inspection purposes.
(We) agree to save, indemnify a keep harmless the City of MISC.- REFER TO ORD.
Cupertino Babilitics,juJg ` s, cost-aU. expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may In, y way accnR>agoimsl si City In Consequence of the
granlin•of ti's ermit. MECH.CONT. LIC.NO. MECH.
h 3-z)-� TOTAL TOTAL
\7/x` Sig to I'Applicant/C tr for Date
OFFICE COPY