12986 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
�,„• �,u!SBUILDING PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT n n
:7 ADOR s
BUIL'DING - ELECTRICAL-PLUMBING-MECHANICAL G `9'
86
OwNER'S PLAN CHECK VALIDATION
N ME
Fat -r/ 1A MIL,(C� OTY. ELECTRIC PERMIT FEE ry(� "� D
MIZUL PI `" PHONE
CONTRACTORS - UTLETS-SWITCHES-RECEP '10.00/1.00 j'-
AMf L //� ''s
�r'h 61V6 66,. ICLm.ND.0/,��, �� LIGHTING FIXTURES 10.00/1.00 s, u
C,0NTRacTOR's � !'" APPLIANCES-RESIDENTIAL 4.00
ADDRESS
$qeo U9a A
PRONE 2�J! PANELS tO.00 DATE OF APPLICATION
RcnrtacT - PANELS (OVER 260 AMP) - 20.00 PLAN CHECK FEES P.C.NO,
OR
ENGINEER -
' sec.rvo. SIGNS TRANS, 3.00 '
ADDRESS
ARCH.DRENG. SPECIAL CIRCUIT. 5.00 PERMIT VALIDATION
Zip TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS ,\,:0 W •`��,"'.
SERVICECHANGE PA in 20,00 20,0 JUN
wO o LICENSED CONTRACTORS DECLARATION - U YP/
U v I hereby affirm that 1 am licensed under provisions of Chapter 9 I I I PI h 9 Q�7 ISSUANCE DATE
H a N (commencing with Section 7000)of Division 3 of the Business and BLD el 4flQ MECH.
F o Professions Code d m,license is in full force and effect '
Z O _ Liccnsc Clxss Lic.Number LL'�ES�jL.5"S� , - y .y IYX'll
O w H
(rE
Uatc Contract or YL`Y of Cupertino
•,¢ m BUILDING PERMIT
a w < OWNER-BUILDER DECLARATION _ INFORMATION
E:
;o. V I hereby affirm that I am exempt from the Contractor's License
MISC.- REFER TO ORD
u 60¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION 5)FT.
� wm-1 Code:Any city orcounty which requires a permit to construct, Q• �a A1-a
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ` V U
DLL requires file applicant for such permit In file a signed statement that TOTAL S PERMITTO
w$ he is licensed pursuant to the provisions o1'the Contractor's License ;;11 J
rza Law(Chapter 9(commencingwith Section 7000)ofDivDion3ofthc �r[J/ 7G0 '/
• 4 O Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
os- 0 the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
R by'my applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN&I (EA.)of not more than five hundred dollars($500).1: . -
❑ 1,as owner of the property,or my employees with wages usBACKFLOW 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 Prolessions ♦ DRAINS-FLOOR,ROOF,AREA,COND. 5.00 -
V:�. Code:The Contractor's License Law does not apply to an owner of -
_ v property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00O SQ FT.FLOOR AREA TOTAL ACREAGE
himid
selflor through his own employees,proved that such improve
' merits are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6,00
of improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
J. builder will have the burden of proving that he did not build or iin- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER: 30.00 RES IND CON PB omen
❑ I,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 IEA.) 1.00
contracts for such projects with a contractors)licensed pursuant to -
_ the Contractor's License Law. - SEWER-SANITARY-STORM EA,200ft/10.00 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 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREA NG EQ IP. 5.00
I fmreby affirm tilt I have a certificale of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,ora certified ENG.SITE NO.
copy lhcHmf(Sec.3800,Lab.C.). I -�•��,��� I I IN O 0 0
Policy N JCAgL t^Z4u+2pany L/II/GRRe .L-fE'�
O ❑ cc Riieddcopyis erebyfumished, FIRE SPRINK ENERGY T-24
z _X
Z ❑ Certified cop . Is f e with the city {pspecY n division. MISC.- ER TO ORD.
O A��licant_� Y ❑ N Y ❑ N❑
~ $ PERMIT ISSUANCE - 10.00
1 CERTIFICATE OPS. TION INS FROM WORKERS' .Q FLOOD ZONE a.L.U.C.
W � COMPENSATION INSURANCE � PLc.coNTR. PLc. •�7}
� Z fThis section need not he completed if the permit is for one TOTAL U b` Y❑ N❑ Y ❑ N❑
hundred dollars IS 100)or less.)
U 0 I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL k- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workeri Compensation Laws of Ce ifornia.
O w - , - BUILDING
y Date Applicant ALTER OR ADD TO M IP 110 5.00
} N NOTICI7 TO APPLICANT: If,after making this Certificate of fix=
(� ? emption,you should become subject to the Workers'Compensation APPLIANCE SQr: 5.00 - PLAN CHECK
provisions of the Labor Code, you must forthwith comply wish FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT _,1Q000QF.M.) 4.00 /
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10 ,F 8.00 ' SEISMIC FEE 9'Y
I hereby affirm that there is,a Ixn.slmcfion lending agency for EXHAUST HOOD (WI Asa UC 1' ' 5.00
the performance of the work for which this permit is issued(Sec." MICROFILM
3097,Civ.C.), 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
1 certify that 1 have read this applic:nion and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city dnd«nmty PLUMBING / -
ordinances and statolaw, relating to building construction, and', BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 i3 6 1
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
�:�•,/' above-mentioned property for inspection purposes. V
/ (We) agree to save, indemnify and keep harmless the City of MISC.-• REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which ERMIT ISSUANCE 10.00 d CONST.TAX
x may in aqQy way accrue against said City in consequence of the P , /
gmnllg 1'lhe:permit. MECH.CONT. LIC,NO. MECH.
TorAt l.5 TOTAL
'gnat sere of Appl' ant Contractor Da '
OFFICE COPY -