12418 (2) y APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
•l�; $UILDING PROJECT IDENTI FICATION PERMITNUMBER
BUILDING APPLICATION & PERMIT
e' >.
ADDRESS
a'
Q \rr� - BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 12418
NWMER 1 V_ mr�ExV`S PLAN CHECK VALIDATION
V1 C< .�1'39� QTY. ELECTRIC PERMIT FEE
ONE W
CONTRACTOR'S
NAME ] ` per OUTLETS-SWITCHES-RECEP 10.00/1.00 Q
�►{ LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'$ADDRESS 4,k% APPLIANCES-RESIDENTIAL 4.00
per\ CIA.11 PXONE-Xy-gyp 0171 PANELS 10.00 DATE OF APPLICATION
ORRCNITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE. P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ncourOsse ENG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 PAID
APPLICANT'SMOTORS SEE FEE SCH.
ADDREDDRESSS �1
SERVICE CHANGE 20.00 MAR 9 - 1987
Woo LICENSED CONTRACTORS DECLARATION
< u u I hereby affirm that 1 am licensed under provisions of Chapter 9 C•
Z i commencing with Section 7000)of Division 3 of the Business and
E Q BLDG. ELECT. ECH.
r N i icenssions Cod and ny license is in full for e[fect�
License ILie
C 117-
0� o Date ontr mr '
A, Y �' BU DING PERMIT
¢ IS ¢ OWNFi R-BUILDER DCCLARA ON
S,
a H. NFORMATION
I'xu 0 w I hereby affam that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
H u o at Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
Code:Any city or county which requiresa permit to construct,alter,
IS ¢ ¢ FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i u G u requires the applicant for such permit to file a signed statement that TOTAL , PERM IT TO
w$w he is licensed pursuant to the provisions of the Contractor's License
ri>
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
sio
¢ r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a by any applicant for a permit Subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP PES.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 themon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
meets are f or
intenugh ds ownemployees,far Sale,
If,however,ed that the
improve- GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
meats are not intended or offered far sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND C PB DrM1Br
prove for purpose of sale.). INDUSTRIAL WASTE INTER: 30.00
❑ d as owner of the property,he rojectiv Se contracting with
andPed acontractors d to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSPAS PARCEL NO.
and Professions Code:The hbuildContractor's License Law does not apply
to tr owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractorfs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACO.FILENO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm(net I have a certificate of consent to self-insure, ZONING
ora certificate of Workers'Compensytlp In�sllyyggrrii��ee a e lified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).wf 1o�' b'- r�
Policy No. Compuny Vin'
Q d copy is hereby furnished.
Z Z p,_Rrt r¢ py is fled w' ly Inspet ion division. FIRE SPRINK ENERGY T34
O Applicant - MISC.- REFER TO ORD. Y [] N� 'Y � N�
LUH CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE , PLG.CONTR. LIC.NO. PLG.
CL Z( This section need not be completed if the permit is for one TOTAL Y[] NE] Y N
hundred dollars(S 100)or less.)
0 O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
UL I- mit is issued,1 shall not employ any person in any manner At as to
O W become subject to the Workers'Compensation Laws of California.
Dane Applicant BUILDING
a ALTER OR ADD TO MECH. 5.00
} m NOTICE:TO APPLICANT: If,after making this Certificate sa Ex- _
L.. Z em vision you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions io the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO)OODC.FM.) 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,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify,lha,I have read this application andstate that the above VENTILATION FAN (SINGLE) . 4.00
information is correct. I agree to comply with all city and county PLUMBING
_ ordinances and state laws relating to building construction, and 801LER-COMP I3 H.P.orlOO,000B.T.U.) 6.00
It
authorize representatives of this city to enter upon the BOILER-COMP IOvar 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 PERMIT ISSUANCE 10.00 CONST.TAX
Xy m any way accrue against said City in consequence of the
gr 4 of this permit. MECH.CONT. LIC.NO. MECH.
\40 - TOTAL TOTAL
Signature of Applicant/Contractor Date
OFFICE COPY