11312 APPLICANT. TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATIONPERMIT NUMBER
aVILDING APPLICATION & PERMIT
ADDRESS 5 I IO I' -� 11312
BUILDING=ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
NAME PLAN CHECK VALIDATION
1 QTY• ELECTRIC PERMIT FEE
vgarvE L( -ICI
NAMERACTaR's UTLETS-SWITCHES-PIECED 10.00/1.00
DptyG'r LIC.NO.3�551 Id LIGHTING FIXTURES 10.00/1.00
ADDRESSTORs PPLIANCES-RESIDENTIAL 4.00
KP yensCr I, L16-IQ PANELS 10.00 DATE OF APPLICATION
oCNITEGT
nnPANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C.NO.
ENGINEER
L¢.NO. SIGNS TRANS. 3.00
ADDRESS ENG SPECIALCIRCUIT 5.00 PERMIT VALIDATION
zlv TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS - MOTORS SEE FEE SCH.
IID(II�//
woo LICENSED CONTRACTORS DECLARATION SERVICE CHANGE 20.00
av 1 hereby affirm that I am licensed under provisions of Chapter 9
rawISSUANCE DATE
a y
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
rDa Professions Co and my license is in full for e` ❑ ❑ ❑
Z z w W Date e,Cl Lic.Number 1
w H_ Date Contractors
Q y E"
in w a - OWNER-BUILDER DECLARATION BUILDING PERMIT
MISC.- REFER TO OR INFORMATION
A.
;LL m I hereby affirm that I am exempt from the Contractor's License V LUATION $/FT.
IFu Oj Lawforthe followingreason.(Seo.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any eny or county which requires a permitto construct,alter, /
( in ¢¢Q improve,demolish,or repair any Structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEL.
E m an mqubes the applicant for such permit to file a signed statement that TOTAL
w he is licensed pursuant to the provisions of the Contractors License PERMIT TO _
Hz
Law(Chapter 9(Commencing with Section 7000)of Division 3 ofthe
¢ ns �1 O
4 D Business and ProfessioCode)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
R I- m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONS R.
a3 - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($5000:
O 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044,Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law data not apply to an owner of
• properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 so.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If.however,the budding GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON O Ot❑ne.
❑ as owner of the property, exclusively contracting with
licensedd contractors to construct thehe ❑ ❑
project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
toan trowner of propertywho builds or,improves licensed pursuant
who LAWN SPRINKLERS-OVER 5(EA.) 1.00
the Co
contracts for such projects with a conlmctoKs)licensed pursuant[o
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ftl10.00 TRACT NO, PARCEL NO.
❑ tem exempt under Sec. ,B&.P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00
ACC.DATE ACL.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to a if-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
ropy thereof(Sec.3800,Lab.CJ. -
Policy No. Company I�SF.t-C�
O "❑ Certified copy is hereby fumished. FIRE$PRINK ENERGY T44
Z Z IA Cenifie o Is filed with the city inspection division.
FQ - Appicant !`7" MISC.- REFER TO ORD. Y0 N� Y❑ N❑
CC y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE ' 10.00 FLOOD ZONE A.L.J.C.
W > COMPENSATION INSURANCE PLG.CONTR_ LIC.NO. PLG_
CL O (This section need not bt completed if the permit is for one TOTAL NC]
::) Z hundred dollars IS 100)ar less.) -
U O 1 certify that in the performance of the work for which this per- QP. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,1 shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
i Date Applicant BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
FZ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1OPWC.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE r
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the pSr mm 'c2_yof the Wok for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). 47q n HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name_
Lender's Addre 1�1t11G(lon L1 HEATING UNIT(OVER 100,000 B.T.U.19.50 ELECTRIC
• I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
I information h comer l agree to comply with all city and wunty PLUMBING f
v ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the g01 LER-COMP (Over 1 ooP00 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.
p` Cupertino against liabilities,judgment$, costs and expenses whichCONST.TAX
may in any any accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gran[in of thisn MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
ignature of a t/Contractor Date
OFFICE COSY