12965 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
SyALDING APPLICATION & PERMIT
DR
)OE55 --�
C � Tn f '� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 12965
Owry ER' IJ�U PLAN CHECK VALIDATION
TY. ELECTRIC PERMIT FEE
p�+ PHON NJ�
CONTRACTOR'S OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.N _79. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
DRE55 �
(PHONE IPANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
_LIC.No, SIGNS TRANS. 3.00
ADDDRESS G. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
aooREs ✓/`/J
SERVICE CHANGE 20.00
0 0 o LICENSED CON'T'RACTORS DECLARATION
a i w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Q w (commencing with Section 7000)of Division 3 of the Beim x and BLDG. ELECT. PLG. MECH.
y z Professions Code o1 1''r se is in full for
Z
9 w o m - Datenx , LIC., n
r o Date Conl actorSC E L
SC Y s BUILDING PERMIT
w ¢ OWNER-BUILDER DECLARATION
A o a INFORMATION
ra N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
Fu04 Law for the following reason.(Sec.7031.5.Business;nd Professions PERMIT ISSUANCE 10.00 VALUATION g/FT.
Code:Any city or county which requires permit to construct,alteq
LE 2 ¢o improve,demolish,or repair any structure,prior to its issuance also ELEC.CONTR. - LIC.NO. ELEC.
CLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT T
E
$ he is licensed pursuant to the provisions of the Contractor's License
Fii Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe �.
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
o ;m_ 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(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 du the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00
Code:The Contractor's License Law does not apply to an owner of
. properly 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-
ments are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4(EA.) 2.00
builder will have the burden of proving that h - . -
e did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 E TIN CON PB DO,
❑ I1:1 ,as owner of the property,um exclusively contracting with
licensed 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 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.200ft/10.00 TRACT NO. PARCEL NO.
O tum exempt under Sec.-,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK Ii RS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby air,,. that I have a certificate Vic.....ent to'elf-insure,
or v certificate of Workers'Compensation Insurance,or a ocri fieri ZONING ENG.SITE NO.
copy th�IpC{$y;.3fQ0,kauy/ i[)„ �yq4{
Policy pony //1./F/ 4 I GM�ywC/_
Q ❑ Ccrtilicd opy i'I creb urniAlPd. (_/�/Px/ FIRE SPRINK ENERGY PZ4
Z Z Cerlifvh coo . h Dm city inspection divi on.
♦- 1 Apficunt E MISC.- REFER TO ORD. YE] NE] Y ❑ N[]
CrN CERTIFICATE OF EXEMP"r10N 17ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD20NE A.L.U.C.
LU 2: COMPENSATION INSURANCE PLG.CONTR. ❑C.NO. pLG
CL ❑ (This section need not be completed if the permit is for one TOTAL Y❑ NE] Y❑ N
:) Z hundred dollars(S 100)or less.)
U O I certify that in the performance of the work for which this pod T' MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any mvnaer so as to
0 Ofbecome subject to the Workcrs'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO 5.00 BUILDING
} Do NOTICE TO APPLICANT: If,after making this Certificate of ,
F _ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply With
en
FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 19 .M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNLTJO R10=_. .16.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HO ITH 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C). HEATING UNIT(T 0 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UN IT(07E A 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION AN (SINGLE) 4.00 information is correct.1 agree to comply with all city and county
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
hereby authorize representatives of this city to enter upon the 801 LER-COMP (Over 100,000 BTU)SEE FEE SCM.
above-mentioned property for inspection purposes. MECHANICAL LP
(We) agree to are, indemnify and keep harmless life City of MISC.- REFER TO ORD.
Cupertino against Liabilities,jl dgmenls, cosh and expenses which CONST.TAX
in any way accrue, gai st said City in consequence of lite PERMIT ISSUANCE
tiL 10.00
rap ng of this I c pME .CONT LIG NO. MECHVAA .
t W<17 �, TorgL� TOTAL
nature of Applican Con ractor UWe ZZ
OFFICE COPY