12629 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
gA"D"" 12629
ADDRE
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OwrvE 'a PLAN CHECK VALIDATION
•� "AME V. ELECTRIC PERMIT EE
SC O PHONE
NAME AroR's _ UTLETS-SWITCHES-RECEP 10.00/1.00
uc.N 00 LIGHTING FIXTURES 10.00/1.00 .
ADDRESS row's PPLIANCES-RESIDENTIAL 4.00
Ebf PHO 3/ /-/v PANELS 10.00 DATE OF APPLICATION
ARCHITECT- PANELS (OVER 200 AMPI 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
a/PA Ic.No. SIGNS TRANS, 3.00
ARCH.OR EN4" IDATION
ARCH. Le e SPECIAL CIRCUIT 5.00
nP EMP.METER OR POLE INS. 20.00 pp�1
ADDRESS rs f/��p /(,/, MOTORS SEE FEE SCH. APR J 1JC7�
ADDRESS `1VE-K /J1/C S
- SERVICE CHANGE 20.00
. 02¢ 2 �E /E FSE
y, LICENSED CONTRACTORS DECLARATION C
Cw � apefiau
<i u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w ¢ "' BLDG. L PLG.
(commencing with Section 7000)of Division 3 of the Business and C .
Professions Cade, y license is in full force ❑` ❑
Z O L aa License Cl
a Co Numbe V
F w Date Contractor
¢ m a a OW ER-BUILDER DECLARATION BLPLDING PERMIT
o a u INFORMATION
wg H I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
w0¢ Lew for the following reason.(Sec.7031.5,Business Professions VALUATION $/FT.
r u m PERMIT ISSUANCE 10.001 JU
w 0 Code:Any city or county which requires permit to construct,alter
¢ Er el o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LID,NO. ELEC.
i O¢ requires the applicant for such permit m file a signed statement that TOTAL ✓ PER IT TO
w m he is licensed pursuant to the provisions of the Contractor's License �\VJ�/4
Fri
Law(Chapter 9(Commencing with Section 7000)of Division 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
M H$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES I TYPE CONSTR.
P. by any applicant for a permit subjects the applicant tozcivilpenalty 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 BACKFLOW PROTECT.DEVICE 4,00 DCC.GROUP PES.UNITS
sole compensation,will do the work;and the structure is not
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-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 does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsamred intended oroffered for sale.l f,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6,00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) 200
builder will have the burden of proving that he did not build or int- - . - . .
RUI ING USE
prove for purpose of sale.). ES IND LON PB "ne,
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 NA ❑ ❑ 0 ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 N4ASSqESSORS PARCEL NO.
and Professions Code:The Contractors License Law docs not apply
loan owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contmctons)licensed pursuant la SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
O.I am exempt under Sac.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
.Owner Uutc WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to Bull'-insure, ZONING ENG.SITE NO.
or a eercontp of Workers'Compensation ,or o certified
th
copy thereof(Sec.3800,Lab.
Policy No._ hereby
Company
Z A❑C Certified copy issherlaill Vih furnished. FIRE SPRINK ENERGY T.24
Z 0 p Certified Py is Ble ith fly ci inspection division.
Fp APlicunt� MISC.- REFER TO ORD. Y N❑ v [D No
E N 10.00
SS
IT Lu ISSUANCE W CIiRTI FICEXEMPTION FROM WORKERS' PERMFLOOD ZONE A.L.u.L.
W COMPENSATION INSURANCE PLG.CONTR, LIC.NO. PLG.
d EJ C] ❑ C]
dollars
(This an Aced not be completed if the permit is for one TOTAL Y Y N
7 2 hundred dollars(S 100)or less)
U OF I certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
0. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ W NOTICE TO APPLICANT: If,after making this Certificate WET
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
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.FM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency I'or EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI NG UN IT(OV ER 100,000 B.T.U.)9.50
Lender's Address - ELECTRIC
I certify that I have read this application and state that the aboveVENTILATION 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 801 LER-COMP(Over 100,000 BTU)BEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless life City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way ace a ago' st said City in consequen a of the PERMIT ISSUANCE 10.00 -
graming this pe MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
3tinagurectAppricamli-ontractor r 94e J_
OFFICE COPY