12769 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
tNEI'
INc APPLICATION & PERMIT
I 'n BUILDING — ELECTRICAL—PLUMBING—MECHANICAL 12769
'S PLAN CHECK VALIDATION
GTY. ELECTRIC PERMIT FEE
cor
NTR TORS UTLETS.SWITCHES-RECEP 10.00/1.00
orr c, LIGHTING FIXTURES 10.00/1.00 -
CONTHACTOR'S APPLIANCES-RESIDENTIAL 4,00
s
V P IO PANELS 10.00 DATE OF APPLICATION
wrecT
OR PANELS(OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO ISIGNSTRANS. 3,00
ARCH.OR ENG. - - SPECIAL OIRGUIT S.QQ PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.012C 2a '—
AvvuCANr$ MOTORS SEE FEE SCH.
AOGRESS
SERVICE CHANGE
wO o LICENSED CONTRACTORS DECLARATION
¢u w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing wi ection 7000)of Division of the usin� BLDG. ELECT. PLG. MECH.
Ni Professions Co u, y license is in full f
z O v,— License lass Con NumbEl 1:1 El Ej
-
9 w r w Uate_��p�_ Contractor_ — _ it
P:
Y f BUILDING PERMIT
¢ ¢ OWNER-BUILDER DECLARATION
E R w v INFORMATION
wOv. MISC.— REFER TO ORD
;a y I hereby affirm that I am exempt from the Contractor's License VALUATION
F u,w j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE - 10.00 O— S/FT.
Code:Any city or county which requires a permit to construct,alter;
Qa, Improve,Q demolish,Or repair any structure,prior to Its Issuance,also ELED.CONTR. LIC.NO. ELEC.
a. wO¢ requires the applicant for such permit to rile a Signed statement that TOTAL PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License
F z a
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT FEE
it = $ the basis for the alleged exemption.Any violation at Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S500).1:
❑ 1,as owner of the properly,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 does not apply to an owner of
• property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 S0.FT.FLOOR AREA TOTALACREAGE t
himself or through his own employees,provided that such improve-
mentsl are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that Ire did not build ar iv'- BUILDING USE
prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively conUacl ing will, ❑ 1 ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORSPARCEL NO.
and Professions Code:The Contractor's License Law dues 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 n nmtructoPs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT N0, PARCEL NO.
❑ I am exempt under Sec. ,BAP.C.lir this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK H RS'COMPENSA'1'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have o certificate of consent to selfinsum, - ZONING ENG.SITE N0. t
or a Certificate of Workers'Compensation Ipslan orrg� a certified
copy t hereof(Sec.3800 Lab.C,). TT (`=f
Policy No. Company_
O J]-Ce Co ertby(rials the
FIRE SPRINK ENERGY T-24
Z Z w✓1'x1l'y C rtl e ) tire y tort_he city inspection Aivision.
p (Cant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ IN
CC = CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. ?oG. AL YE] N[3 Y❑ NE]
Z f1'his section need not be completed if the permit is for one
hundred dollars IS 100)or less.)
U O 1 certify that in the perfornruncn of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workers Compensation Laws of Calilbrnia.
n Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
1..- Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with - FEE
V such provisions or(his permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MCF.M.) 6.00 SEISMIC FEE
I hereby affirm that (here is a construction lending a ency for EXHAUST HOOD (WITH DUCT) 5.00
the performan h vork f Ihid permit is e. a (Sec. MICROFILM
3097,Civ.CJ. �� HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name _ HEATING UNIT(OVER l00,000B.T.U.0,50
Lender's Addre s ELECTRIC
1 certify that 1 have read this application and state(hat the VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP13 H,P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino ago' liabilities,judgments, Costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
a y ny garde add st said City in consequence of the
gra I g a n LL CH.CONT.' LIC.NO. MECH.
�. TOTAL TOTAL
igna f plican[ ontmaor Date
OFFICE COPY -