12011 (2) APPLICANT TO FILL IN, INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
/
.y acILOINc` ADOREss
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 12011
OWNER'SPLAN CHECK VALIDATION
NAME 4116, OTY. ELECTRIC PERMIT FEE y
SPHONE '
CONTRACTORS
rv//A��M,�EOUTLETS-SWITCHES-RECEP 10.0011.00
A15 .Q /iZe77s GIC.NO.�o-D�J LIGHTING FIXTURES 10.00/1,00
CONTRACTOR'S
VailPPLIANCES-RESIDENTIAL 4.00
!A'/D,/O•R/'Ess
f� � �(c�{„/ PHONE q4eP'o of 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. PER MIT VALIDATION
5
ADDRESS SPECIAL CIRCUIT .00 ry q y�
ZIP EMP.METER OR POLE INS. 20.00 7 (j 1986
APPLICANTS MOTORS SEE FEE SCH.
I
ADDRESS
SERVICE CHANGE 20.00 City Of Cupertino
00 LICENSED CONTRACTORS DECLARATION
a zw I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
„ ¢ (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. L MECH.
F�'^ Professions Co an my license is in full fare J ff cL ❑
z o n License Class Lic.Number 3 ❑
yH w Dale Con orator G
¢ y f
¢ a OWNER-BUILDER DECLARATION BUILDING PERMIT
a o s MISC.- REFER TO ORD INFORMATION
X ;a I hereby affirm that I am exempt from the Contractor's essame
uO¢ Law for she following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE VALUATION SIFT.
� - Code:Any city orcounly Which requires a permit to construct,alter, - 10.00
G ¢ G 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. -
LL requires the applicant for such permit to file a signet statement that TOTAL P qMl=TO
w$ he is licensed pursuant to the provisions of the Contractor's License �vO
HiQ Law(Chapter9(commencing with Section 7000)of Division 3 of she
4 D Business and Professions Code)or Nat he is exempt therefrom and QTY. PLUMBING PERMIT FEE
W1- the basis for the alleged exemption.Anyviolation ofSection7031.5 STORIES TYPE CONSTR.
i ;� by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5,00
of not more than 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 sole(Sec. 7044, Business.,to Pml'esswn,s 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 SD.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.) 200 BUILDING USE
builder will have The burden of proving that he did not build or im- . . . INC CON PB Omer
prove for purpose Of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors 1. construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
Hill Professions Code:The Contractor's Licens'c Low 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 contraclorls)licensed purslane to SEWER-SAN, V-STORM EA.200ft/10.00
the Contractors Lire ase Law, TRACT NO. "PARCEL NO.
❑ I am exempt under Sec.-,BARC.far this WATER HEATER W/VENT 6.00
ea n
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSA'I'ION D17CLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a cerlifaamo f consent to sel Giname' ZONING
or a certificate of Workers''Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec 3800,Lab.CJ.
Policy No. Company
O ❑ Celfifiedcopyisherell fu Rshed. FIRE SPRINK ENERGY T 24
of - is f ith a 'nspection division.
p Applicam MISC- REFER TO ORD. Y ❑ N❑ Y ❑ No
W CIi rw]CATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLDOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG,CONTR. LIC NO. PLG ��
1 0 (This section need not be completed if the permit is for one TOT.AL Y❑ N❑ Y❑ N❑
:D 2 hundred dollars($100)or less.)
U 0 I certify that in the performance of the work for which Nis per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f out is issued,I shall not employ any person in any manner so as to
O W become subject to tile io
e Workers'Compensatn Laws of California. BUILDING
Q. Dam Applicant ALTER OR ADD TO MECH. 5.00
} SO NOTICE TO APPLICANT: If,after making this Cenificale of Bx-
)... ? 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.CJ.
Lender's Name H EATING UNIT(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 above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating 10 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
above-mentioned property for inspection purposes. BOILER-COMP IOver 100,000 BTU)SEE FEE BCH. MECHANICAL
(We) agree msave, indem and keep harmless the City of MISC.- REFER TO ORD.
Cupertino aguir liabilities, gmen[s, costs and expenses which CONST.TAX
may in any way accrue Inst said City in consequence of the PERMIT ISSUANCE 10.00
grand this er 1. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
imature of icanl/ConUaclor I Wie
OFFICE COPY