12241APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE ALL POINT PEN ONLY
BUI'LDI NG PROJECT I DENTI F ION
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A0330 ��/ENr
APPLICATION & MIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
12241
OWNER
"nm _ /y'
PHONE J)i4 0
CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONT
CONTE rGR'sNAME
ytFAtAj 7 Pl4.111716. LIC.N.Ca7l1a9
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
ADDRESSTGRs
Dw1^0
(eta so ,,(140;^^ %C3gJ-a-9)L*
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT
DR
ENGINEER
LIC. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG'
SPECIALCIRCUIT 5.00
PERMIZy ION
TEMP. METER OR POLE INS. 20.00
ZIP
DEC2 2 low
ADDRESS ra
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
v 4 4.
a
LICENSED CONTRACTORS DECLARATION'
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, ah y license is in full force un fed.
License Class-�. Lic. Numbers'% -
Date{],._],.�, g(p Contractor
ISSUANC
BLDG. ELECT.
❑ ❑
L MECH.
❑
BUILDING f ERMIT
OWNER -BUILDER DECLARATION
I hereby affirm that I on exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand Professions
Code: Anycily orcounty which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
INFORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTE. LIC. NO.
ELEC.
TDTAL
he is licensed pursuant to the provisions Of the Contractor's License
CITY. PLUMBING PERMIT . FEE
1
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
5 RIE
TY E ONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant fora pennitsubjects the applicant to a civil penalty
of not more than five hundred d.IUrS (5500).):
ALTER -DRAIN & VENT -WATER (EA.) 5.00
❑ I, as owner of the property, or Thy employees with wages as
their sole compensation, will do the work, and the structure is Hol
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
Vt. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or Offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that Such improve-
mentsare not intended oroffered for sale. If, however, the building
'
7 FIXTURES - PER TRAP 5.00 35:w
SG. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that the did not build or im-
prove for purpose ofsale.).
❑ 1, as Owner of the properly, am exclusively conlracting with
GAS - EA. SYSTEM -OVER 4 IEA.) 2.00
BUTUSE
RES IND CDN PB Omeh
❑ ❑ ❑ ❑ ❑
INDUSTRIALWASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts Icor such projects with a contractor(s) licensed pursuu n1 to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec. ,BAPC. for this
,Cason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACG FILE N0.
WATER TREATING EQUIP. 5.00
WORK Ii RS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure.
or a certificate of Workers' Compensation Insurance, or a ei rlified
ZONING
ENG. SITE NO.
copy theirk9L(Sec. 3800, Lab.C.).
PolicYNYj1-M,cOmpany_.i'f�. �U
-
FIRE SPRINK
Y❑ N❑
ENERGY T24
v❑ N❑
❑ Certified copy is hereby furnished
'11111 -Certified copy is filed with the city inspection division.
Applicant
MISC.- REFER TO ORD.
CERTIFICATE OF EXFMPT10N FROM WORKERS'
PERMIT ISSUANCE 10.00 IO.O
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for One
PLG. CONTE. LIC. NO.
PLG. r
TOTAL q11 0-
Y ❑ No
Y ❑ N❑
hundred dollars (SIDE) or less.)
I certify that in the performance of the work Icor which this per-
mit is issued, I shall not employ any person in arty manner so as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: IL after making this Certificate of lix-
emplion, you should become subject to the Workers' Conhpensm ion
APPLIANCE 5.00
PLAN CHECK
provisions of the Labor Code, you MUST forthwith Comply with
such provisions or this permit slhall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT (OVER IQOOOC.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the
perfo3097, rmance of the work for which this permit is issued (Sec.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lender's Name
Lender's Address
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
ordinances and state laws relating to building construction, and
PLUMBING
gO1LER-OOMP13 H.P. Dr 100,000 B.T.U.1 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE $CH.
MECHANICAL
hereby authorize representatives of this city to enter Upon The
above-mentioned property for inspection purposes. '
MISC. - REFER TO ORD.
(We) agree to save,indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
ma any way accrue, against said City in consequence of the
ORR(I of is permit.
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
azure of Applicantntractor Uatc
OFFICE COPY