12604 APPLICANT TO FILL' IN INF RMATIO WD
WITHIN RELINES -.USELL POINT PEN ONLY
BUILDING PROJECT I DENTI FI ON PERMIT NUMBER
BUILWNG APPLICATION & P IT 12.604
AD DH a�_73o v
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^/ BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER'Sr ' PLAN CHECK VALIDATION
NAM 6�I�/,l !`� Clip X4)3 • OTY. ELECTRIC PERMIT FEE
• W`V✓ ' I '1 PHONE a
CONTRACTOR'S UTLETS-SWITCHES-RECEP 10.00/1.00 r
rvA
LIC.N . LIGHTING FIXTURES 10.00/1.00 -
CONTRACTOR'S s? APPLIANCES-RESIDENTIAL 4.00
AD RE55 I , {' J
71 'IJ �1 PHOrvE� ��0 PANELS 10.00 DATE OF APPLICATION
4
ARCHITECT - � PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE - P.C.NO.
OR
ENGINEER
LIC.NO, SIGNS TRANS, 3.00
ADD Ess Ervc. r '. SPECIAL CIRCUIT '5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH.
ADDRESS DNEEE q
� SERVICE CHANGE 20.00 / / b /
o m i, i�I '
0 0 LICENSED CONTRACTORS DECLARATION
a E,u I.Isereby affirm thin 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y<w (commencing with Section 7000)of Division 3 Of the Business and SLOG. ELECT. PLG. MECH.
professions C.0Rrf7, license is in full ford .
z o H - License lass [[.•// Lic.Number ' _ ❑ ❑ ❑ .�
4 r w Date e/�Cnn[mclor -
x s '/ -R BUILDING PERMIT
E Ix w OWN iR-BUILDIiR DECLARATION INFORMATION
oa MISC.— REFER TO ORD
E
; LL h I hereby affirm that I am exempt from the Contractor's License VALUATION
HLLOa Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 :6/FT. .
Code:Any city or county which requires permit to construct,alter,
SE
M Q improve,demolish,or repair any structure,prior to its issuance,also ELEC..CONTR: LIC.N0. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w he is licensed pursuant to the provisions of the Contractor's License �
F i a Law,(Chapter 9(Commenciagwith Section 7000)of Division 3 ofthe �
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
M r $ the basis for the alleged exemption.Any violation of Section 7031.5 - STORIES TYPE CONSTR.
age by any applicant for a permit subjects the applicant to acivil penalty gLTERrDRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):.
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES,UNITS
sale 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 1
Code:The Contractor's License Law doesnot apply to an owner of
properly who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale,If,however,the building GAS-EA.SYSTEM-,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 he did not build or'Im-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
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 contraclods)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00
the Contractor's License Law." TRACT NO. PARCEL NO.
❑ I am exempt Linder Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM - 5.00 ACC.DATE ACC FILE NO.
WORKERS'COMPENSAIION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to sel Ginsure' ZONING ENG.SITE NO.
or a.certifcale of Workers'Compenwl' n nSo ranee,err a certified
copy thereof(Sea 3800,Lab.C.E
Policy No. Company
O ❑ Certifiedco Lercby hum' led. FIRESPRINK ENERGY T-24
ZZ ❑ Certified II d w' 1 t By inspection division. MISC.- REFER TO ORD.
O ApplicamY ❑ N❑ Y ❑ N❑
~ rn - PERMIT ISSUANCE 10.00
� CERTIFICATE OF :M filo ROM WORKIiR$' FLOOD ZONE A.L.U.C.
W D COMPE TIO SURANCE PLG.CONTR.. ,LIC.NO. PLG.
0- Z (This section need not be completed if the permit is for uric - TOTAL Y❑ N[_ Y ❑ NE)N
hundred dollars(S 100)or less.)
U O �I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mil is issued,I shall not employ any person in any manner so as t0
O W become.subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD-MVP H- 5.00 BUILDING
} to NOTICE'TO APPLICANT: If,after making this Certificate of ISx-
?• emption,you should become subject to the Workers Compensation APPLIANCE ,
PLAN CHECK
provisions of the Labor Code, you cost forthwith comply with f) FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING O: QODOC.F,M,) X4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UN%gE .16.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD UCT) - 5.00
the performance of the work for which,this permit is issued(Sec. MICROFILM
3097,Civ.0.). ! HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4,00
information is correct. I agree to comply with all city and courry PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,0008.T.U.) 6,00
hereby authorize representatives of this city to enter upon the BOILER-COMP IOVar 100,000 BTU)SEE FEE SCH. MECHANICAL a
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harraless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichCONST:TAX
perm'
may'in way ace against said City in consequence of the PERMIT ISSUANCE' - 10.00
gran' 0I this MECH.CONT. LIC.NO. MECH.
[I TOTOTAL
Signature of li tractor to -,
OFFICE COPY - _ -