12595 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
BUILDING PROJECT IDENTIFICATION . PERMIT NumBER
BUILDING APPLICATION & PERMIT
ADDRESa
/I bk- BUILDING— ELECTRICAL—PLUMBING—MECHANICAL 12595
OWNER'S V - PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.60/1,00 '
N E _
LIc.NO. - LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S - - APPLIANCES.- 4.00 ''•�,r rte/•
A00 S �/(y�lj��I� - - -
�O �41.t%/`� PHONE(�j�— PANELS "10.00 T OF APPLICATION.
ARCHITECT- PANELS(OVER 200 AMP) 20.00 -PLA " K a P.C.NO.
OR
ENGINEER -
ua No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT .5.00 P M��7
�WlgnoN
ADDRESS -• J7YC)
ZIP rrEMP. METER OR POLE INS. 2000. ITY Uh
APPLICANT'S - - MOTORS SEE FEE SCH. C(JYCf1I Bilu
ADDRESS } y .
1• t SERVICECHANGE 1 20.00021
j/�/���
wo O LICENSED CONTRACTORS DECLARATION - s �T": /�
<u v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H a N (commencing with Section 7000)of Division 3 of the Business anti - BLDG. ELECT. PLG, MECH.
F y z
Professions Cod�iWmd., se is in full force anyfffec.-zom— License ILic.Number OO o yw DateContractor DIiR DIiCLARATION .. BUILDING PERMIT
a Iz: w INFORMATION
oa REFER TO ORD
wR. u_y I hereby affirm that I am exempt from the Contractor's License MISC.—
u04 Law foi,the followingteason.IS".7031.5,Business slid Professions'. PERMIT ISSUANCE 10.00 ,VALUATION $/FT.
Code,Any city or county which reclulresa permit to construct;alter, _
rt ¢ o improve,demolish,or repair any stmcture,.prior to its issuance,also ELEC.CONTR. ELEC. '
F. pO a requires the applicant for such Pemdt to file a signed statement that _ TOTAL -I PERMIT TO
6 W 9 ,A IIC Is licensed pursuant t0 the provisions at lite Contractor's License ,
Hzr Law(Chapter 9(commencing with Section 7000)of Division 3 of lite
4 Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
r the basis for the alleged exemption.Any violation of Scction 7031.5 ,- STORIES TYPE CONSTR.
u ;$ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).): _ - -
❑ I,as owner of the property,or my employees.with wages us 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.
Code:'The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who docs sack walk FIXTURES-PER TRAP 5. SO.FT,FLOOR AREA TOTALACREAGE
j himself or through his own employees,provided that such Improve- -
�,. mmits are nut intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 -
or immr
proveent is sold within one year of completion,the owneGAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or inl-
Prove forpurposeofsale.). INDUSTRIAL WASTE.INTER: 30.00 RES IND CON PR One,
Cl 1,as owner of the property,:mit 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 contructoos)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License law.. TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec' ,B.&P.C.for this WATER HEATER W/VENT .6.00
reason
.Owner Date - WATER SYSTEM. ' S t�
ACCYOATE ACC.FILE NO.
WORKERS'COMPFNSA'f10N DECLARATIONWATER TREATING EQUIP. - -• 5.00 ,• -
I hereby affirm out I Imve a carificnte ol'consenl to soil-insure.
or acertifteme.of Workers Compensation Insurance,or a cer ified _ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
C ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
0 Applicant Y-C] N[] Y ❑ N[D
~ — PERMIT ISSUANCE
CERTIFICATE OF P-XBMI']'ION FROM WORKERSFLOOD ZONE A.L.u.c.
'
W > COMPIiNSATION INSURANCE. PLG.CONTR. LIC.No. PL '
11 O ('Phis section need not be completed'if the permit is far one TO i.0 V❑ N ElY❑ N❑
Z hundred do1lar4($100)or Icss.) -
U O I certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I'shall not employ any person in any manner so as to
U become subject totile Workun'Con.punwfail Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} rn NOTICE TO APPLICANT: If,aNer,omking this Certificate of fix- - -
F.. Tz emption,you should become subject to Om Workers'Compensation APPLIANCE 5,00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
f..1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=r-F.M.) a 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,Cw.C.). - HEATING UNIT(TO 100,0008.T.U.) 8.00
Lender's Name•
Lender's Address HEATI NIS UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
® I certify that 1 have read this application and state that the_above VENTILATION FAN (SINGLE) 4.00 -
information is correct. 1 agree to comply with all city and county PLUMBING
BOILER-COMP(3 H.P.Or 100,0008.T.U.I 8.00
ordinances and state laws relating to building construction, and
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, indemnify and p harmless the City of misc.- REFER TO ORD.
Cupertino against'habilities,judgment osis and expenses which CONST.TAX
may in any y accrues against sat hty in consequence of the PERMIT ISSUANCE 10.00
gran 0 perm MECH.CONT. - LIC.NO, MECH. Q
z1z °T"•` TOTALC�
u of Apptcanl/Contruc r. Date '
DIFFICE COPY -