12328 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
x ADDRESS12328
20990 CfJEiwyl Dom, BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION ,
• \<
"AME OTY. ELECTRIC PERMIT FEE
c sa PHONE2-13- y
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 U
NAME
6/1
LIC.NO. LIGHTING FIXTURES 10.00/1.00 U -
CONTRACTOR's PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
'LIC rvo. SIGNS TRANS. 3.00 -
ARCH.oRENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE IN 20.00
APPLICANT'S MOTORS EE FEE SCH. _ �D
ADDRESS SERVICE CHANGE CHANGE 20.00
'02 LICENSED CONTRACTORS DECLARATION a / ^"A1
c u w 1 hereby affirm That I am licensed under provisions of Chapter 9 .J'�.' ' ♦ )`r� ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
Z Professions Code,and my license is in full force and effect. ❑ ❑
z
0. - License Class Lic.Number •-- -. �
9Date Contractor !�
y f I -,v _ , yam BUILDING PERMIT
¢ ir w < OWNER-BUILDER DECLARATION - P ` `"'- INFORMATION
o,d ° - MISC.- REFER TO ORD
K 1 hereby affirm that 1 am exempt from the Contractor's License VALUATION S/FT.
w I.O< Law for the following reason.(Sec.7031,5,Business and Professions PERMIT ISSUANCE 10.00
� - Code:Anycity orcounly which requiresa perrnittoconstruc(,alter, 0
2 K ¢a improve,demolish,or repair any structure,prior to its issue ce,also ELEC.CONTE. LIC.NO. ELT ? �f'
a a O W requires the applicant for such permit to file a signed statement that TOTAL C PERMIT TO
w$m he is licensed pursuant to the provisions of the Contractor's License �LE� x�
Fi> Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
f 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 703 L$ ' STORIES TYPE CONSTR.
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(8500).):
❑ I,as owner of the property,or my employees with wages as
their 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 F IXTURES"PER TRAP 5.00 Set FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenot intended orOffered for sale.if,however,the budding GAS-EA.SYSTEM-1'INC.40UTLETS 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 am- RES IND CON PS Other
prove for purpose of sale.). INDUSTRIALWASTE INTER, 30.00
C31,as owner of the property,am exclusively contracting with - ❑ ❑ ❑ ❑ ❑
licc III 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 M�__
AWNSPRINKLERS-OVER 6(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant toSEWER-SAN V-STORM 0.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
rt�gg I am exemptunder Sec. ,B.&P.C.for thisER W/VENT 6.00
I reason
7. Owner 4 Date M ACC.DATE ACC.FILE NO,
WOO RS'COMPENSATION DECLARATION TING EQUIP. 5.00
I hereby affirm that I have a certificate Of consent to self-insure, - ZONINGor a certificate Of Workers'Compensation Insurance,ora certifed ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). ,2 �0Policy No. Company f��/O ❑' Certified copy is hereby furnished -�_D"/ ' g� FIRE SPRINK ENERGY T44
2 ❑ Certified copy is filed with the city inspection divson. TO ORD. y❑ N❑ y ❑ N❑
0 Applicant _
~ tnPERMIT ISSUANCE 10.00 0� FLDOD ZONE A.L.u.c.
CERTIFICATL'OF EXEMPTION FROM WORKERS'
LU COMPENSATION INSURANCE PLO.CONTE. LIC.NO, PLG.AL ICOIL' y N OU ❑ ❑ ❑
D' a (This section need not be completed if the permit is for one TOTy N
Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance Of the work for which this per. OTY. 'MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner So as to
0 become subject to the Workers'Compensation Laws of California. BUILDING
Date ApplicantALTER OR ADD TO MECH. 5.00
} Do NOTICE TO APPLICANT: If,ufit,making this Certificate of Ex-
? 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 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 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.C.).
Lender's Name HEATING UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC �Y•�-
Lender's Address
I certify that l have read This application and state that the 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-COMP(3 H.P.or 100,000 B.T.U.) 6.00 / 4
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. `✓1
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino againsL- bififies,judgments, casts end expenses which - CONST.TAX
m In By wayagainst aid City in consequence of thePERMIT ISSUANCE 10.00gr n' A)lei5 pMECH.CONT. LIC.NO. MECH.TOTAL TOTAL �'
&gnaNre o`A licanl/Coni actor Dale
OFFICE COPY