12184 APPLICANT TO FILL IN INFORMATION WITHINIRED LINES -'USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER ,
-�` auILDING APPLICATION PERMIT
ADDRESS ; 1 2 1 8 4•
✓�. LO�� ING -ELECTRICAL-PLUMBING-MECHANICAL'
H ,PLAN CHECK VALIDATION
r "AME OTV. ELECTRIC PERMIT FEE
�✓Po:�%
DAMTo OR, 17 OUTLETS-SWITCHES-RECEP 10.00/1.00 j '� -
I LIGHTING FIXTURES 10.00/1
AD s .00
P, Nr AcroRs APPLIANCES-RESIDENTIAL ' 4.00
,
PHONE PANELS .
10.00 ' DATE OF APPLICATION
CHITECr
- o PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
E Q/�
SIGNS TRANS. 3.00
ADDREOR SS ENc. I v SPECIALCIRCUIT - "5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
s APPLICANT'S - MOTORS SEE FEE SCH.
ADDRESS ✓I� l�
SERVICE CHANGyE 20.00
0 0 0 , LICENSED CON'T'RACTORS DECLARATION
a u. I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE.
w Q H (commencing with Section 7000)of Division 3 of the Business and -� ��� - SLOG. ELECT. - PLG. MECH.
H w z I'ro fessions CoL-ensc is in full for W.,
:z o w - , License CI ss I-ic.N in ❑ ❑ ❑
2 w Dam Contractor
¢ y f ` BUILDING PERMIT
¢ a w u OWNER-BUILDER DECLARA'f1 - E�p INFORMATION
X ;u w I hereby affirm that 1 am exempt from the Contractor's License VALUATION- S/FT.
H .. O¢ Law for the following reason.(Sec.7031'.5,Business and Professions PERMIT ISSUANCE 1 .00 '- - -
Code:Any city or county which requiresn permit to Construct,Our,
2 Q 2 improve,demolish;or repair any structure,prior to its issuance;also ,
C
requires the applicant for such permit 16 file a signed statement that TO PERMIT TO
a ism he is licensed pursuant to the provisions of the Contractor's License r
Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the
¢ Business and Professions Code)or that he is exempbtherefrom and OTY. PLU GING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation at Section 7031.5 I STORIES TYPE CONSTR.
n $m by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN&VENT-WATER,(EA.) 5.00
- of not more than five hundred dollore(8500).):. -Cl I,as owner of the property,or my employees with wages as BACKFLOW PROTECT. DEVICE' 4.00 Oce.GROUP RES.UNrts
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 .
Cade: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 50.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve
meats 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- GAS EASYSTEM-,OVER 4 IEA.) 2.00
builder will have the burden of proving that h - . .
e did not build or im- _ ButLOING USE
prove forpurpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Otha,
❑ I,is owner of the property,am exclusively contracting with ❑ ❑ ❑ '•❑ Q.
licensed contractors to construct the 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
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(0 licensed pursuant to SEWER-SAN EA.200ft/10.00 '
the Contractor's License Law. TRACT NO. PARCEL NO.
Cl ,I am exempt under Sec. r ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner/ `^/ Dale WATER SYSTEM •5.00 ACC.GATE ACC.FILE NO. r
!N R111i1 ' 7Txrfl ION DIiCLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of c.D,cnt to self-insure,
or n certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO. -
copy thereof(Sec.3800,Lab.C.). -
Policy No. Company rr.�S '
I QCertiftedcop is) reby I hed. . FIRE SPRINK ENERGY Tod
Z ZO p tCCnvifi I the ty nspection Division. MISC.- " REFER TO ORD. Y N Y N
EC rn PERMIT ISSUANCE 10.00 ❑ ❑ ❑ ❑
Lu - f,I;RTI FICCOMPE F CMI"1'10 AN WORKERS'• FLOOD ZONE A.Lu.C. t
W •' COMPEN ATION IN 2ANCIi PLG.CONTR. LIC.N0. - PLG. ,
CL Z (This section need not be completed, if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
hundred dollars IS 100)or less)
U O 1 certify that in the,performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
"SL T- mit is issued,I,shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
Lai Dom ' Applicant OR ADD TO MECH. . 5.00 BUILDING
} ED NOTICE TO APPLICANT'. If,after making this Certificate of Ex-
F 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SWC.F.M.) 4.00
CONSTRUCTION LIiN NG AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE _
I hereby affirm that there: is a co struction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
fire performance of the work w ch this permit is issued(Sec. MICROFILM
3097,Civ.CJ, H EATING UN IT IT
100,000 B.T.U.) 8.00
Lender's Nam HEATING UN IT(OVER 100,000 B.T.U.)9.50 - Dee
Lender's Address ELECTRIC
I certify that I have read this application and state that the above 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-OOMP(3.H.P.or 100,000 B.T.U.) 6.00
��- hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indenmit'y and,keep harmless the'Clly or 's- MISC.-'. REFER TO ORD.
Cupertino against li bilines jddgmenls, costs'and expenses which CONST.TAX
may in any ay ccrue ni t said Cty in sequence of the PERMIT ISSUANCE 10.00
gran rs rI MECH.CONT. LIC.NO. MECH.
r e TOTAL TOTAL
Sig lu of Applicant/ ntraclor ate - -
? ICE COPY
LJ - /