12846 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE B LL POINT PEN ONLY
BU LDING PROJECT 1 DENTI FIC 1 . PERMIT NUMBER
BUILDING APPLICATION & PEWT 12846
y ADDRESS
/ T) - BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
ow ER's PLAN CHECK VALIDATION
6..
NAME FL6R PHONE _7 Q (J,''TY. ELECTRIC PERMIT FEE 3$�
' r
CONTRACTOnS.
/. NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 /0 -
S uc.ND, SQ LIGHTING FIXTURES 10.00/1.00
CONTRALTO Ws
ADDRESS
CONTRACTOR
APPLIANCES-RESIDENTIAL 4.00
CON
A!;tom$ _V L, HONE3t5,3-PIS PANELS 10.00 DATE OF APPLICATION
AARRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECKFEE P.C.NO.
O
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENa. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 1lNw
aPPucarvrs MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 Q/
o D LICENSED CONTRACTORS DECLARATION Q .Z,`S 7
a uU I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
mai (commencing with Section 7000)of Division 3 of the Business and BLOC. ELECT. I PLG. MECH.
H w i Professions Code,a my license is in full force - e f
2 o m- License CI s - Cmn Numbm �
o - Date Contractor 21
a m - BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION '•
¢ WO - INFORMATION
w3 LL N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u0a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00116 "- VALUATION $/FT.
- A Code:Any city or county which requires a permit toconstruct,alter,
¢ � improve,demolish,or repair an structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
Q G o PY P ELEC. 911
O¢ requires the applicant for Such permit to file a signed statement that TOTAL ll(/ PERMIT TO
R
$w he is licensed pursuant to the provisions of,the Contractor's License ))��qq _
H i) Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe �-f1{J J (�
i c Business and Professions Code)or that Ise is exempt therefrom and OTY. PLUMBING PERMIT FEE
BE $ the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant ma civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ 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 does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
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 im-
prove for purpose ofsale.). INDUSTRIALWASTE INTER. 30.00 RES IND CON , P8 Omer
.❑ 1,as owner of the properly,am exclusively contracting with .❑ ❑ ❑ ❑ ❑
licensed contractors toconstruct 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
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SAN 1000
ARY-STORM EA.200ftI .
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec, ,B.&P.C.1'ur this WATER HEATER W/VENT 6.00
aeon
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of Consent to self-insure,
x or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE N0.
copy thereof(Sec.3800,Lab.C,.
Policy No. Company
O ❑.Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z O Certified copy is filed with the city inspection division.
Applicant MISC.- REFER TO ORD, Y❑, N❑ Y ❑ N❑
~ yPERMIT ISSUANCE 10.00 0 -- FLOOD ZONE
CERTIFICATE OF EXEMPTIONFROM WORKERS' A.L.U.C.
-
LU COMPENSATION INSURANCE PLG.CONTR, LIC.NO. PLG
IL �-yV ❑ ❑ [:] ❑
0 (This section need not be completed if the permit is for one TOTAL Y N YN
::) Z hundred dollars IS 100)or leas,
U O 1 certify that in the performance of thew.ork for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issu I shall not employ an r person n any manner so as to
U beco s ec to the Workon xwa: n vs of California.
a Date Applicant J( a ALTER OR ADD TO MECH. 5:00 �-- BUILDING
} to NOTIC.TO APPLICANT'. If al r making this ertificate of Ex
? eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
Prone
of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY- AIR HANDLING UNIT(OVER 10=C.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. - HEATING UNIT(TO 100,000 B.T.U.). 8.00 MICROFILM
3097,Civ,CJ.
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.500-0
Lender's Address ELECTRIC 30
I certify that I 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 state laws relating to building construction, and BOILER-COMP(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 BTU(SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agreeto save, indemnify and keep harmless.the City of MISC.- REFER TO ORD.
Cupertino a ainsl Babilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 Q- CONST.TAX
ny way rue gal id City in icos;;qc;ce Of thegrant g of this perms MECH.CONT. LIC.NO. MECH.
OTAL �S_ TOTAL �Z/0icant/Co [ra a
OFFICECOPY -