12214 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NG PROJECT 1 DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 2214^q A
AppnE55 �FQr? wi�y�N Gr' BUILDING-ELECTRICAL-PLUMBING-MECHANICAL GG 14
OWNER'S PLAN CHECK VALIDATION
NAME O ELECTRIC PERMIT FEE
L Svf1 L DrvE 5 9- 7
croRs
NAME UTLETS-SWITCHES-RECEP 10.00/1.00 0
NAME
LIC.No. LIGHTING FIXTURES 10.00/1.000.-
CONTRACTOR
DDRESs APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMPI 20.00
ENGINEER
Lic.NO. ISIGNSTRANS. 3.00
ADDREss Ervc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS
AnDRESSPLICANMOTORS S FEE SCH.
/
SERVICE CHANGE 0.00
woo LICENSED CONTRACTORS DECLARATION
F i W I hereby affirm that I am licensed under provisions of Chapter 9 ^Ylj 5LJrV _ ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.-
H n w Professions Code,and my license is in fulbforce and effect O ❑ ❑
Z 0 y License Class Lic.Number dt
9 m r Dale Contractor
s- BUILDING PERMIT
se c ¢ OWNER-BUILDER DECLARATION
o s" MISC.- REFER TO ORD INFORMATION
w ;u I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
r u w at Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE - 10.00 Q
Code:Any city or county which reyuiresa permit toconstruct,alter,
Q to M Q improve,Jem011sh,a!repair any sINCNIrL`,prior t0 Its ISSn:111Cq aI50 ELEC.CONTR. UC.N0. ELEC. Q a
i y 0 u requires the applicant for such permit to file a signed statement that TOTAL C.1 PERMIT TO
w$ he is licensed pursuant to the provisions of the Contractor's License �LEL7
r Law(Chapter 9(commencing with Section 7000)of Division 3 of the
ic Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
r $ the basis for the alleged exemption,Any violation of5ection 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-gpt more than five hundred dollars($5001):
f. I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00
tl ei sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec, 7044, Business and Processions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code;The Contractor's License Law does not apply to an owner of
.. properly who builds ar improves thereon,and who does such work FIXTURES-PER TRAP 5.00 s0.FT.FLOOR AREA TOTAL ACREAGE
' himself or through his own employees,provided that such improve
-
mentsarenotintendedorofferedforsole.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•EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES ]NO CON PB Omer
❑ 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:T'he Contractor's License Law does not apply
to an owner of property who builds or improves Ounenn,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 -
Contracts for such projects with a contraclons)licensed punuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B,&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dam WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificateofcoment toself-insoM,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby fumisied' FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
~ w PERMIT ISSUANCE 10.00
W - CERTI FICATEONSATIOPTI NS FROM WORKERS' FLOOD ZONE A.L,U.C.
W � COMPENSATION INSURANCE: PLG.CONTfl. LIC.NO. PLG.
Q. O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
:3 Z hundred dollars(S 100)or less.)
U O I certify that in the performance of the work for which this per- GTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so us to
become Subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICI7 TO APPLICANT': If,after making this Certificate of Ex-
� 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 be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRuCT10N LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.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,CNC.). HEATING UNIT ITO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 Gv
Lender's Namess ELECTRIC �Q .��
I certify that l 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 PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMPI3H.P.or100,000B.T.U.) 6.00
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 keep harmless the City of MISC.- REFER TO ORD.
Cupertino agl' s Babilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in a wa a e against said City in consequence of the
gmntln f lhi er MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signl. o Applicant/Contractor lc
OFFICE COPY