12817 A
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING DIN 03Al, Wo fj APPLICATION & PERMIT 12817
1 I ^ Y� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S 6 PLAN CHECK VALIDATION
•X NAME - QTY. ELECTRIC PERMIT FEE
r. ✓'\ PHONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
N Atm rr ll I
Yl i>h1 J1 Al uc.N 1`fOS� LIGHTING FIXTURES 10.00/1.00
roNTRACTOR's LC/ APPLIANCES-RESIDENTIAL 4.00
A3a. �r fp
E C
(ygON ��T PANELS 10.00 DATE OF APPLICATION
ORRCHITECT •,et11p ✓[L /C,g. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER IV
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 20.00
ADDRESs NT'S
AMOTORS SEE FEE SCH.
OREs
SERVICE CHANGE 20.00 w, ��� 17
ow
'02 LICENSED CONTRACTORS DECLARATION !'►�
a u I hereby affirm that 1 am licensed under provisions of Chapter 9 NCE DATE
yaw (commencing with Section 7000)of Division 3 of the Business and B CT. PLG. MECH.
Professions Codynd license is in full fo d •ffec ❑ ❑
Z o,'v'n- License Class ` '" Lia Number C OS� O
o w Dam Contractor,
a m s SS ����a¢aa���....n��snFFn ILDING PERMIT
¢ ¢ w
OWN[i R-BUILDER DECLAR'AII INFORMATION
w 3 LL N 1 herebyatone that 1 am exem t from the Cuntruc x's License MISC.- REFER TO ORD
g p Businessand Professions VALUATION $/FT.
LL o ¢ Law for the followin reason(Sec.7031.5, PERMIT ISSUANCE 10.00
- ,4 J Code:Any city or county which requires a permit to construct,atleq
¢¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
0¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT 0
a w m" he is licensed pursuant to the provisions of the Contractor's License ('r
H z a
LAW(Chapter 9(commencing with Section 7000)of Division3of the E4 ��
4 O DTV. PLUMBING PERMIT FEE
Business and Professions Code)or that he is exempt therefrom and
¢H $ the basis for the alleged exemption.Any violation ofsection 7031.5 STORIES TYPE CONSTR.
w. by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).1:
❑ I,as owner of the property,or my employees with wages as BACK F LOW 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 so.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-11NC.40UTLETS 6.00
menu are not intended or offered for sale.It;however,the building
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 lllat he did not build or im- RES IND CON PB Ome,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,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 (EA.) 1.00
cmuraels for such projects with a contractor(s)licensed pursuant to
SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ Iamexemplunder Sec: .B.S.P.C.for this WATER HEATER W/VENT 6.00
R asml
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACL.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a1 certified
copy thereof(Sec 3800,Lab.C). S ! „YG FU N el-
Policy No. Company tF-N
O ❑ Csrlilicdcopyishereby furnished. FIRE SPRINK ENERGY T 24
Z 2 / �❑ Certifie�lfoPy is filerwith th�7 ity inspection division. MISC.- REFER TO OR D. Y ❑ N❑ Y C] N❑
F- Ori' Applicant
CC W CERTIFICATEOI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 -,,DOD
Ql > COMPENSATION INSURANC17 PLG.CONTR. LIC.NO. PLG. ❑ N❑
Q- Q ('fills section need not be completed if the permit is for one TOTAL
Z hundred dollar.,(SIOO)or less
U O 1 certify that in the performance of the work for which this per- QTY' MECHANICAL PERMIT FEE FEE SUMMARY
l.L F ns it is issued,I shall not employ any person in any manner sn as to
O w become subject to the Workers Compensation Laws of California. l7
ING
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILD �yCs
} W NOTICE.TO APPLICANT: If,after making this Certificate of Ex-
f" Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK G 9A
'provisions of the Labor Code, you must forthwith comply with FEE O ��
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE , rV
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,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Nanm HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lenders AdJess
. I cefity that I have read this application and slate Ilett Ole above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-CDMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTUI SEE FEE SCH. MECHANICAL
above cutioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way 311 rue against Said City in consequence of the PERMIT ISSUANCE 10.00
graIof thisp�i MECH.CONT. LIC.NO. MECH. ,�
f �ofA ^I tmCttOr 77Q TOTAL TOTAL a
Signature of Applicant/Contractor Uale� I I
OFFICE COPY