12112 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BDILMNG APPLICATION & PERMIT 12112
aooR ss
t jALC L � �'A5� Ito IJ pa (Z,�', BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
T' N4MEii A CITY. ELECTRIC PERMIT FEE
0 PHONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
fQ,M1 L AaD VBrzT: LIC W.VY&I LIGHTING FIXTURES 10.00/1.00
COO ACToRS �.3- � PPLIANCES-RESIDENTIAL 4.00
ADDRESS �
/ _•/ PJ��I� QS HONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP TEMP.METER OR POLE INS. 20.00
APFLCANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION 0.110
a ix U I hereby affirm that I um licensed under provisions of Chaplet 9 ISSUANCE DAfE
N< w (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. 1 PLG. MECH.
F y i Professions CodLa license is in full fore e�/ r _❑ .a ❑
z o a- leas. C Lic.Numbe((�� LrL,�{/:�s..�
C,7Contractor,}LLX _ dKY�'
Q L �j Otl' x 1
BUILDING PERMIT
Q a w u OWNER-BUILDER DECLARATION INFORMATION
w1 a- y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION S/FT.
F u o j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct.alter,
6 a,Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT Tp
a w m he is licensed pursuant to the provisions of the Contractor's License �! /
z t
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and OTY- PLUMBING PERMIT FEE
a o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500)J:
❑ I,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:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SG,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve-
mentsurenot intended or offered for sale.IL however,the building GAS-EA.SVSTEM-1 fi.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 an- RES IND CON PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ El 1:1
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS FARCE L 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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
the Contractor's License Law.
❑ I um exempt under Sec. ,B.&P.C.hrr this WATER HEATER W/V ENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORKERS'COMPENSAT10N DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insur ace,or a certified
copy N000fISec C.11pim00. ,. A�.�.
Policy N It Company
Q ❑ Cnrtille c pY is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certifi Jed with Otn city inspection division. MISC.- REFER TO ORD.
F O Applicant y N❑ v❑ NE]
cc: - CERTIFICATE OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v❑ N❑ Y ❑ NJ(]O (This' section need not he completed if the permit is I'or one TOTAL
Z) Z 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 H mit is issued.I shall not employ any person in any mannerin,as to
O W become subject to the Worker;Compensation Laws of California.
BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} tail NOTICE TO APPLICANT: If,after making this Certificate sa Hx-
F ? cnmision you should become Co e, you
In the Northers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you muss forthwith comply with AIR HANDLING UNIT(TO 10 C.F.M.) 4.00 FEE �!
C..1 such provisions or this permit Shall be deemed revoked. .�
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 6.00 SEISMIC FEE SO
1 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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender;Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
• I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
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
abovemlentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino a ainst liabilities,judgments, costs and expenses which CONST.TAX
may in wa a rue a last said City in consequence of the PERMIT ISSUANCE 10.00
g n I � a6MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
of Ap c nl o tactor Dat
OFFICE COPY