12482 c° .APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
BUILDING f O 12482
yC ADOREss �k
BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
1-1 wNER's PLAN CHECK VALIDATION
NAME QTV. ELECTRIC PERMIT FEE
PHDx�s3s�ro7p/
CONTRACTOR'S
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10,00 DATE OF APPLICATION
4RCHITECTPANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. ISIGNS TRANS. 3.00
ARC H.OR ENG. 5.00 PER MIT VALI DATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS IMOTORS SEE FEE SCH. (t -
ADDRESS
SERVICE CHANGE 20.00 ((,�
woo LICENSED CONTRACTORS DECLARATION ��Q,
< u U I Beeby affirm tlml 1 am licensed under provisions of Chapter 9 ISSUANCE DPT
y <w (commenting with Section 7000)of Doisiun 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and effect. ❑ El El
D m - License Class Lic.Number
Q rr Date
Contractor
< BUILDING PERMIT
R w
OWNER-BUILDER DECLARATION INFORMATION
w 3 a- N I herebyaffirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
p VALUATION S/FT.
a,O a Law for the following reason.(Sea 7031.5,Business and Professions PERMIT ISSUANCE 10.00
� - v, Code:Any city or county which rnquiresafermlt to Construct.alter,
¢ ¢Q 0 improve,demolish,or repair any structure,prior to its issuance, f%
also ELEC.CONTR. LIC.NO. ELEC.
requires the applicant for such permit to file a signed statement that TOTAL O PERMIT TO
whe is licensed pursuant to the provisions of the Contractor's License �S ��G�
Fzr
Law(Chupter9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
r O the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
oby an applicant
for.fort Permiitsubjcundred dtts s(the applicanttma civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole cmnpensution,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
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5,00 50.FT,--FLOOR TOTALACREAGE
himself or through his ownemployces,provided that such improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
Dumas rc
ms anot intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
.i builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 E] El El
❑
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sea 7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPARCEL NO.
and Professions Code:The Contractor's License Law docs 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
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I ant exempt under Sec.—,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Ilia--'------ WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSAT'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have IT certificate of consent Io lelf-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY L24
ZZ ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ NE]F Q Applicant
� y CERTIFICATE OIs EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C.
Ul > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (This section need not be completed if the permit is for one TOTAL - Y❑ N❑ Y [3 N❑
D Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,1 shall not employ any peruIn in any manner so as to
Ow become subject to the workers'Compensation Laws of California. BUILDING
Dale Applicant ALTER OR ADD TO MECH. 5.00
} DO 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
provisions of the labor Code, you nuts( forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR'H D hf A 4.00
CONSTRUCTION LENDING AGENCY AD I (O 10=C:FMU 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for ET
T HORQ(W IT.H)DUCT) � 5,00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. ` H G UNI (TO 100t,000 B.T.U.1 8.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.19.50 ELECTRIC 30 �
Lender's Address
1 certify that 1 have read this application and state that the above V xA OM__Fr_ (($ _ ( 100
information is correct. I agree to comply with all city and coumy BOILER- ( .6 ,.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
above-mentioned 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 accrue against said City in consequence of the PERMIT ISSUANCE 10.00
grant of this permit L� MECH.CONT. LIC.NO. MECH,
t asiat/rz
5-00-P7 TOTAL TOTAL
Si a .APphCan/Cont, or Date f
OFFICE COPY