12052 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ON Lo"
BU LDI NG PROJECT I DENT]FICATI ON /1,PERMIT NUMBER
BUILDING
AV/ q U APPLICATION & PERMIT 12052
l 1 DING - ELECTRICAL-PLUMBING-MECHANICAL �(
OWNER's, // '',, A� - PhpN CHECK VALIDATION
NAMED G.(IMACI Z�..E � � DTV. ELECTRIC PERMIT FEE
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.NO. LIGHTING FIXTURES 10.00/1.00
f-DHTRACTOHY APPLIANCES-RESIDENTIAL 4.00
ApDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.0.N0.
OR
ENGINEER
LIC.NO. - SIGNS TRANS. 3.00
ARC"ESS ENG. SPECIALCIRCUIT S.DD PERMIT VALIDATION
ZIP ,EMP:METER OR POLE INS, 20.00 J
APPLICANT S MOTORS SEE FEE SCH. rrN-/J�•,�E
ADDRESS
SERVICE CHANGE - 20.00
'0O LICENSED CONTRACTORS DI?CLARA'I'ION
a v w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
a,< w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H y z Professions Code,and my license is in fall force and effect. ❑ ❑ ❑
z 0 m - License Class Lic.Numbar _
z w Date Contractor
ad f d - BUILDING PERMIT
w u OWNER-BUILDER DECLARATION INFORMATION
woa MISC.- REFER TO ORD
1 hereby affirm that I am exempt from the Contractor's License
F Ic0ar Law for the followingreasun.(Sec.703 1.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION SIFT.
Code:Any city or county which requiresa permit[.construct,alter,
Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
o u requires the applicant for such permit to file a signed statement that TE
u w $ he is licensed pursuant to the provisions of the Contractors License PERMITTO
H z >w Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
Ic the basis for the alleged exemption.Any violation of5ection7031.5 STORIES TYPE CONSTR.
e. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
.their sole compensation,will do the work,and the structure is LEE OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code: The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP S.DO $O.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees.provided time such improve-
ments
nt building
mmselfc not through
oroffered emploeesale provided
thathowevsthebmlding GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im-
prove for purpose ofsale.). INDUSTRIALWASTE INTER. 30.00 'RES IND CON PB Othe,
❑ I,as owner of the property,am exclusively contracting with ❑ El ❑ 11 Q
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
RMSATIONDECLARATION
ojects wish a commands)licensed pursuant togEWER-SANITARV-STORM EA.200ft/10.00nse Law. TRACT NO. PARCEL NO.
nder Sec. ,BAP.C.for this WATER HEATER W/V 6.00
Date WATER SYSTEM - ,+5.00 ACC.DATE ACC.FILE NO.
'COMI'IiNSATION DECLARATION WATER TREATING EQU P 0 V-'J 5.00
1 hereby affirm that I have a certih"c of consort to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.CJ. !J. ,
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER WOR O Applicant V ❑ IN Y ❑ N�
X rn PERMIT ISSUANCE 10.00
LU - CEiRTI FICATE E I ATIOTINS FROM WORKERS' FLOOD ZONE a.L.U.C.
W � COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLc. /
CIL Z (This section need not be completed if the permit is lot one TOTAL Y N� Y N�
hundred dollars(5100)or less.)
U O 1 certify that in the performance of the work for which this per, OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD,TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
H Z 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
C..1 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 10=C.EM.) 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,CR.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 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 t.comply with all city and county PLUMBING
ordinances and state laws relating ID building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to
to enter upon the
above-mentioned property for inspection purpoBOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree ave, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino)))p am sabilities,juit encs, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may inITay accrue agaipe� 'ly ' consequence of the
grant! his erand. MECH.00NT. LIC.NO. MECH.
v3 TOTAL TOTAL
l
Si tum of APPLE t/Contr or Date
OFFICE COPY ,