12271 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY .
its BU LDI NG PROJECT 1 DENTI FICATI ON PER NUMBER
BUILDING APPLICATION & PERMIT
AOOREss 12271 '
^� I / ff/`� ✓n BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OW o. W /V PLAN.CHECK VALIDATION
NAME ,v PRDNE
CITY. ELECTRIC PERMIT FEE
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CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
NAM qc�// q
s.Na.
/t O LIGHTING FIXTURES 10.00/1.00
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
ADDRESS /�/ p/1 y/� py
p�'/1/( Fy yJ*.PQ ONE �`*7i/y PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
O
OR P //
ENGINEER I/,Wttn U ('Ar I/✓
1//WIM• fFKIC No. ( SIGNS TRANS. 3.00
AGGRESS ENG. 7 SPECIAL CIRCUIT 5.00 PERMIT VALIDATION 1
fLp L�1Fs.I(Ty zip / EMP.METER OR POLE INS. 20.00 /1 , ,, J
APPU C ANTS MOTORS SEE FEE SCH. ll ll•^'A,/1-P-^-
ADDREss
SERVICE CHANGE 20.00 I G
Go LICENSED CONTRACTORS D17CLARATION Y
a v w 1 hereby affirm that I am licensed under provisions of Chapter 9 E DATE
(commencing with Section 7000)of Division 3 of the Business and D E PLG. MECH.
Professions Coda d my license is in full for c Z ❑ ❑
IN
a; o 2 - Ll cense Cs s (Q Lic.Number
Q F OwlUuteJ�Z��Contractor
JM %P9MLDING
¢ Q w ¢ OWNER-BUILDER DECLARATION INFORMATIONT
MISC.- REFER TO ORD
w I- I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
to LL o a Law for the following r asun.(Sec.7031.5,Ilusinessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requiresa permit to construct,alter, Li �S a
2 ¢ improve,demolish,or repair any structure,prior 10 its issuance,atm ELEC.CONTR. LIC.NO. ELEC.
a¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w2 he is licensed pursuant to the provisions of the Contractor's License
Hii Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ H0 the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
n ; - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
Plum
more than Five hundred dollars(S500).):
C11,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,GOND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 sa FT.FLOOR AREA TOTAL ACREAGE
e himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-11NC.40UTLETS 6.00
menu are not intended or offered for sok.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA.) 200 BUILDING USE
builder will have the burden of proving that he did tint build or im . . .
REB IND , CON PB Oren
prove for purpose of sale-). INDUSTRIAL WASTE INTER30.00 -
❑ 1,as owner of the prop .property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractor, to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSES RS 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 contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ff/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
unison
Owocr Date WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a ce Rlficate of conscm to Alf-inure, ZONING
or a cenil irate of Workers'Comttr vulrµcc,qr a cert ifed ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). rt/I✓/�
Policy No. Company /USO
O ❑ Certified copy is he yby to hcd. FIRE SPRINK ENERGY T.24
Appk -Cenified c TILd//Ipl, he
city inspection division. MISC.- REFER TO ORD. Y N Y N
71�r(✓ ❑ ❑ ❑ ❑
i - CERTIFICATE 01°EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.LU.C.
LU COMPENSATION INSURANCE PLG.CONTR. ❑c.NO. PLG.
EL O This section need not be completed if the peanut is for one TOTAL Y❑ IN Y❑ N❑
Z hundred dollars(S100)or less.)
V O 1 Lenity that in the performance of the work for which this per. OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,I shall not employ any person in any manner so as to
U
Vbecome subject to the Workcri Compensation Laws of Califomu.
w Date Applicant BUILDING
a ALTER OR ADD TO MECH. 5.00
} w NOTICE TO APPLICANT: If,after making this CenifmWe of Ex-
Z emption,you should became 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 10OW CFM.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirn that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the 3097,performance of Inc work for which this permit Is Issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lenders Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COW(3 H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP loser 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the'Cily of MISC.- REFER TO ORD.
Cupertino agRiblies,judgene costs and expenses which PERMIT ISSUANCE 10.00CONST.TAX
may a vgainst sail City in consequence of theNn f MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature u Applicant/Contractor Date V
OFFICE COPY