12689APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION .
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
12689
mWILDING
Apo_ry(s
IT/l
O
NU
QTY. ELECTRIC PERMIT FEE
P-
LAN CHECK VALIDATION
PRONE
CONT CTORS
NA
OUTLETS - SWITCHES -RECEP 10.00/1.00
""��
/yOc. No.
DATE OF APPLICATION
LIGHTING FIXTURES 10.00/1,00
rONTRACTORS
ADDRESS
�(✓ (f T
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
RDXITEDT
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
ISIGNS TRANS. 3.00
ARCH.
oo Ess END..
SPECIALCIRCUIT 5,00
IN VALIDATION
ZIP
EMP. METER OR POLE INS. 20.00
pR 2 31987
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
^��ofCu
YI
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions CodeA,d 'cosi is in full force and effect
License Class CC..
ISSUANCE DATE
BLDG. ELECT. LG MECH.
❑ ❑ ❑
Ue[e Conlromor
ControNumber for
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter,
BINFORMATION IIT
MISC. - REFER TO ORD
PERMIT ISSUANCEVALUATION
10.00
$/FT.
ELEC. CONTR. LIC. NO.
ELEG
TOTAL
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
P RMIT TO
Law (Chapter 9 (commencing with Section 7000) Of Division 3 .1 the
Business and Professions Code) or that Ise is exempt therefrmn and
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant fora porn dollars 500).licam toacivil penalty
of not more than rlva permit dollars the applicant
QTY. PLUMBING PERMIT FEE
STORIES
PE COrvS R.
ALTER-DRAIN-WATER(EA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
DRAINS -FLOOR, HOOF, AR EA,CON D. 5.00
FIXTURES - PER TRAP 5.00 -
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve.
ments are not intended or offered for sale. If, however. the building
SO. FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or an-
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
-
GAS EASYSTEM
- . -OVER 4 (EA.) 2.00
'
BUIL ING USE
RES IND o PB Other
11 ❑ 1:1 ❑
INDUSTRIAL WASTE INTER3000
. .
licensed contractors to construct the project (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
V.B. . .
LAWN SPRINKLERS - 1 INC 5 00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSES50 SPARGE: NO.
contracts for such projects with a contractor(s) licensed pursuant to
the Contractors License Law.
❑ [am exempt tinder Sec.-, B.&P.C, for this
reason
SEWER -SAN V -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00 a
ACC.OATE
ACC FILE NO.
WORKERS'COMPHNSAT10N DECLARATION
WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self -insure,
ZONING
ENG: SITE NO.
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof (Sec. 3800, Lab.C.).
Policy No. Company
❑ Certified Copy is cmby furnished
❑ Certified co IS filed with _,fly inspection division.
Applicant
FIRE SPRINK
Y ❑ N ❑
ENERGY T-24
Y ❑ N❑
MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTIO FROM WORKERS'
COMPENSATION INSURANCE
(This rection need not be completed if the permit is fie one
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y ❑ N ❑
A.L.U.C.
Y ❑ No
PLG. CONTR. LIC. NO.
PLG.
TOTAL
hundred dollars ($100) or less.)
1 certify that in the performance of the work for which this per-
Hit is issued, I shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
become subject to the Workers' Compensation Laws of California:
ALTER OR ADD TO MECH. 5=1
Date Applicant
BUILDING
NOTICI7 TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10,000C.F.M.) 4.00
PLAN CHECK
FEE
emption, you should become subject it, the Workers' Compensation
provisions of tau: Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCPION LENDING AGENCY
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.
3097, 0,C)
MICROFILM
HEATING UNIT [TO 100,000 B.T.U.) 8.00
Lender's Name
Leader's Address
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
V ENTI LATI ON FAN (SINGLE) 4.00
I certify that I have read this application andstate that the above
information is correct. I agree to comply wif, all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER -COM P(3 H.P.Dr100,000B.T.U.) 6.00
801 LER-COMP lover 100.000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
a
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said Cit in consequence of the
granting of dhuLvaefjlit.
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
'
Sig arc of Applicant/Contractor Date
OFFICE COPY