12843 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
aDILOING APPLICATION & PERMIT
A°°qEs / / 12843
'ar BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNIR H�,j PLAN CHECK VALIDATION
.� DTV. ELECTRIC PERMIT FEE
GQ ��I/Zy`C( (L� PHONE/Q�S4
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.NO. LIGHTING FIXTURES 10.00/1.00
C.ONTRACTORs
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ARCH.OR ENG. h5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 20.00
APPhacnrvrs MOTORS SEE FEE SCH.
RESS
ADD
• SERVICE CHANGE 20.00 / 1�J
Ocz jFoo LICENSED CONTRACTORS DECLARATION
< U u I hereby uflinu that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
< y (commencing with Section 7000)of Division 3 of the Business and SLOG. ELECT. PLG. MECH.
r N z Professions Code,and my license is in full force and effect. El ❑ 11z o w- Liecuse Class Lia Number
O 2 F Ow Late Contractor
< yBUILDING PERMIT
Tw OWNER-BUILDER DECLARATION INFORMATION
w0 LL h 1 hereby affirm that 1 am exempt from t he Con frac tot's License MISC.- REFER TO ORD
Fuoa, Law forthe following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION SIFT.
Code:Any city or county which requires a permit to construct,alter,
6 Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement Chat TOTAL ? PERMIT TO
wm he is licensed pursuant to the provisions of the Contractors License
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe L� lr
a PLUMBING PERMIT FEE
Business and Professions Code)or that he is exempt therefrom and QTY.
at o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aim by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
fact more titan five hundred dollars($500).):
❑ 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 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
• properly who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 S°.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.SYSTEM-I INCA dWyfS 6.
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove l'or purpose of sale.). INDUSTRIAL WASTE INT 30.00 ❑ El El El ElO Las owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 IN .B. ASSFSSORSPARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OV I 1.00
contracts for such projects with a contractors)licensed ponuml to SEWER-SANITARY-STORM EA.200ft/10,00 TRACT NO. PARCEL NO.
the Contractor's License Law.
0 I am exempt under Sec. .BARC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORK FRS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a cerliticale ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sce.3800,Lab.C.). - S'
Policy No. Company
O 0 Certified copy is hereby furnished. FIRESPRINK ENERGY T 24
Z z .0 Certified copy is Ned with the city inspection division. MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ No
Applicant _
fLN CERTIFICATEOF-EXIMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 4 FLOOD 20NE A.L.u.c.
ll.l >_ COMPIiNSATION INSURANCE PLG.CONTR. LIC.No. PLG. / Y❑ N❑ Y❑ N❑
CL ❑ (This section need not be cormleled if the permit is for one TOTAL (O
Z) 2 bundPddollars(S100)or less,)
U O 1 certify that in the performance ofthe work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
mit is issued,I shall not empty any person in any manner so as to
Ow LL
become subject to the Workers Compensation Lawsol'California. BUILDING
Datc Applicant ALTER OR ADD TO MECH. 5.00
>- N NOTICE'1'0 APPLICANT: If,after making this CCI il'icate of Ex-
e
♦- Z mption,you should become subject to the Workeri 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 10,C00C.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 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. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
(certify that l haverad t his application and slate that the above VENTILATION FAN (SINGLE) 4.00 PLUMBING 6 7L,
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
ordinances and stale laws relating to building construction, and
hereby aulhoriee representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may 'n any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gra H g of this permit MECH.CONT. LIC.NO. MECH.
99//+pp 2 /S/g7 TOTAL TOTAL
Signa[�ph�/Contractor Date
OFFICE COPY