12600 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
-BUI LDI NG PROJECT I DENTI FICATI ON - PERMIT NUMBER
BUILDING APPLICATION & PERMIT 1 Z6OO
ADORESS I
r ZGU�J SV\.SVS, BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S , ,.PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
AY\h P-A«-_..Q PHONE
CONTRACTOR S UTLETS-SWITCHES-RECEP 10.00/1.00
NAME'
LANIGHTING FIXTURES .10,00/1.00
CNTRACTOR'S
AOpNESSRAC - PPLICES-RESIDENTIAL 4.00
It 7 PHONE IPANELS 10.00 DATE OF APPLICATION
AARRCHITECTf•uNN AV6%Oi . 111-tow(. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.'NO.
O
ENGINEER JJ • '
- I.C.No. SIGNS TRANS. - 3.00
ADDRESS ENG. '- SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
ADDRESS is " MOTORS SEE FEE SCH. -• n (I,�rpAF"�
SERVICE CHANGE .2 0.00 7
0 o LICENSED CONI'RACI'ORS DECLARATION
a is w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w a a. (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT., PLG. MECH,
H 40 z Professions CoAkk and m license is in full fur`c anA e(fenl. -Z
z OmQ-/ License Class S�Lic.Nonnberf�Y-7�3'�'�'2' -' ❑ r• ❑ ®� ❑
9 y I- in
LI. T_ �Z Contractor_M.�r.Ce_
c m f,� - - BUILDING PERMIT
¢ ¢w OWNER-BUILDER DECLARATION - INFORMATION
R
O n I- I hereby afGrmrthat I am exempt from the Conlmaor's License MISC.- REFER TO ORD
�+U. rA y P VALUATION SIFT.
r w0 4 Law for the following reason.(Sec.7031.5,Buslnessend Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
re to Q R.G improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONT .LIC.NO. ELEC.,
O LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
Es
$ he is licensed pursuant m the provisions of the Contractor's License - , n�
F Z r Law(Chapter9(commencing with Section 7000)of Division 3 ofthe ?4d
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
3 i o
¢ I- � the basis for the allegeG exemption.-Any violation of Section 7031.5 STORIES TYPE CONSTR.
i_; applicant for a permit subjects tem applicant too civil penalty ALTER-DRAIN&VENT-WATER (EA.)'5.00
of not more than five hundred dollars(S5000.): -
❑ 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:1'he 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 ' sD.Fr.FLOOR AREA TOTAL ACREAGE
1
0 himself or through his own employees,Provided that such improve-
mentsare not intended oroffered for sale.If,however,the building GAS•EA.SYSTEM-I INC.4 OUTLETS 6,00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that h .e did not build or im- RES IND CON PB Ome,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
El 1, ❑ El 1:1 1:11.as owner of the property,am exclusively contracting with
_ licensed contractors to-canstruct the project(Sec. 7044,Business LAWN SPR INKLER$-1,INC 5 V.B. '6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1:00 -
contracts for such projects with a contractor(s)licensed,pursuant to SEWER-$ANITA MEA.200ft/10.00 TRACT NO. PARCEL NO.
the Ca ntractor s License Law.
❑ Iemexemptunder Sec. ,BAP.C.for this WATER HEATE /VENT 6.00
reason
Owner Date WATER SYSTEM C 5.00
PCC.DATE F ACFILE NO.
WORKERS'-COMPENSATION IMCLARATION WATER TRE JN EQUIP. 5,00
I hereby affirm that) have a certificate of consent to self-insure. ?A ZONING ENG.SITE NO.
ora certificate of Workers:Compensation insurance,tu
e, ra certified V
T copy thereof(Sec.3800,Lab-C) >t"
- Policy No. CompmyL�lE%4'9..5.61.1�APfa--i
O ❑ Certified copy is hereby Intrusted FIRE SPRINK ENERGY T$4
Z Z ❑ Cerlifie cup fi FiJll Th` �ity inspection div me, ' MISC.- REFER TO ORD.
LU
~ $ CIiRTIFICATE PERMIT ISSUANCE 10.00 •V•- - FLOOD ZONE A.L.u.c.
EFROM WORKERS'
W >_ COMPENSATION TION INSURANCC PLG.CONTR. LIC.NO. PLG.
_d O ('Phis section need net beCompletedif the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
::) 2 hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
W Date Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of,fix-
• ♦- 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 he deemed revoked.' AIR HANDLING UNIT(TO 10=C.F.M.)- 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
_ I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the Performance of the work for which this permit is issued(Sec. - - MICROFILM
3097,Civ.C.). t HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lenders Address HEATI NO UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
• 1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 - - 0`0
information is correct. I agree to comply with all city and countyPLUMBING rP
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,0008.T.U.) 6.00
hereby authorize representatives of this city W enter upon the BOILER-COMP (Over 100,000BTUISEE FEESCH. 'MECHANICAL
bo
ave-mentioned Properly for inspection purposes
e)
(Wagree to save, indemnify and keep hon.nless'the City of MISC. REFER.TO ORD.
Cupertino against liabilities,judgments, costs mal expenses which CONST.TAX .
may in anyway acerue•against said City in'consequence of the PERMIT ISSUANCE 10.00
9T Ing of this permit. MECH.CONT. "LIC.NO., MECH.
7: TOTAL TOTAL
"I, Signor re of Applicant/Commafor Date
OFFICE COPY + - "