12911 (4) APPLICANT TO FILL IN INFORMATION WITHIN.RED LINES - USEP L POINT PEN ONLY
BU I LDING PROJECT IDENTI FICA PERMIT NUMBER
�j aNlLol"G APPLICATION & PERMIT
ADDRESS
JG,
�E � BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12911
OWNER'S v PLAN CHECK VALIDATION
"AME OTV. ELECTRIC PERMIT FEE
EI W4 PNONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00 W -
LIGHTING FIXTURES 10.00/1.00 Q .�
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS y�,J,
PNONE 211, S PANELS IO.DO DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC.No. ISIGNS TRANS. 3.00
ARCH.OR ENG. 5 00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP TEMP.METER OR POLE INS. 20.00 u
APPLICANTS MOTORS SEE FEE SCH. -�/n�✓ w
ADDRESS 1
SERVICEC 20.007L� o /
w o o LICENSED CONTRACTORS DECLARATION
Q u U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
us w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Z
H w i Professions Codec and Its i arse is in full fo c ❑
z o m License Class-L�-(�_Lic.Numbe ggsg ❑ ❑
0z �+ Dale_!,(.�..e��Q�Contracmr �yI W
a y f -+�+�'� cm BUILDING PERMIT
Q R w u OWNER-BUILDER DECLARATION INFORMATION
A. o MISC.- REFER TO ORD
X ;A r I hereby affirm that 1 am exempt from the Contractor's License VALUATION S/FT.
hA 00 Law for the followingreason.(Sec.7031,5,Businessand Professions PERMIT ISSUANCE 10.00 O
FN0J Code:Any city orcounty which requitesa permit to construct,alter,
Q 6 Q Improve,demolish,Or repair any structure,print to its issuance,also EL Q CONTR. LIC.NO. ELEC. ,{
requires the applicant for such permit to file a signed statement that, >!' TOTAL �(/ �- PERMIT TO
X $.w he is licensed pursuant to the provisions of the Contractor's License' E�.EG,T
ri> Law(Chapter 9(commencing with Section 700()of Division 3 ofthe /
a 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 7031.5 STORIES TYPE CONSTR.
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(5500).):
❑ 1,as owner of the property,or my employees wills 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
Cade: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 TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 6.00
mems are not intended or offered for sale.If,however,the budding
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-- ,RES IND CON' PB Otte.
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively conlracting with
licensed contractors to construct the project ISec.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 as owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts fur such projects with a contractors)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200th/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under See..,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 WCC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have acertificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy Cher�o(f 3
Z Z Poli NoIA/d r/��� i y�
Q VCetlh led co a music FIRE SPRINK ENERGY F34
.❑ CeN.I n with t ins ection division.
0 / Applicant i MISC.- REFER TO ORD. y❑ N❑ y ❑ No
N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LI-I a COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG, V NF] Y N❑
CL o (This section need not be completed if the permit is for one TOTAL
0 Z hundred dollam IS 100)or less.)
0 0 1 certify that in the performance of the work for which this per- QTY'. MECHANICAL PERMIT FEE FEE SUMMARY
LL IF-. milis issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5,00
} N NOTICE TO APPLICANT: If,after making this Certificate bf Ex-
Fz emplion,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10J000 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 6.00 SEISMIC FEE
1 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.1 8.001MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC Q
Lenders Address
I certify that l 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
v ardinnnces and state laws relating In building construction, and
BOILER-CQMP(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) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino agains ilities,judgments, costs nd expense which CONST.TAX
may in any Denim said Cit conseque of lh PERMIT ISSUANCE 10.00
gmnlin permit MECH.CONT. LIC.NO. MECH.
�1 TOTAL TOTAL
Signature of Applicant Contmc or Date
OFFICECOPY