12909 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
_ BUI LDI NG PROJECT 1 DENTI FICATION PERMIT NUMBER
APPLICATION& PERMIT OINO
ny Q
'FAzRzS ` BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12909
OWNER'SPLAN CHECK VA LIGATION
�AVE Q, �dL-�a.OTV. ELECTRIC PERMIT FEE
b e P,a w+o r P £�e� G94,ws3
CONTRACTORS
ciORs OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No, LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'SAPPLIANCES
-RESIDENTIAL 4.00
ACOma.
PHONE PANELS 10.00 DATE OF APPLICATION
Rcw1ECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
O
OR
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S - 'Z✓
AGGRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
02 LICENSED CONTRACTORS DECLARATION
< u bU I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y a w (Commencing with Section]000)of Division 3 of the BllSlfleaa and BLDG. ELECT. PLG. MECH.
F y i Professions Code,and my license is in full force and effect. ❑ ❑ El
z o m- License Class Lic.Number
9 m r
J Date Contractor .
- -
a y f BUILDING PERMIT
a ¢w u OWNER-BUILDER DECLARATION
w0 LL H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
.. oin Law for the following reason. 7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION SIFT.
- Code:Any city Dr county which requires a permit to construct,alter,
Qp Q improve,demolish,or repair any structure,print to Its issuance,also ELEC.CONTR. L 0.NO. ELEC.
- DLL requires the-applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$w he is licensed pursuant to the provisions of the Contractor's License
rz > Law(Chapter 9(Com me acing with Sect ion 7000)of DMsion3 Effie [�Q
Q Business and Professions Code)or that he Ecxempt therefrom OTY. PLUMBING PERMIT FEE
o and
[he basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER IEA.) 5.00
aI'not more than five hundred dollars($500).)',
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 06E 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
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
KI mems are not intended or offered for sale.If.however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). . INDUSTRIAL WASTE INTER. 30.00 1:1❑ I,as owner Of the property,ton exclusively contracting with
licensed contractors to Construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCE L 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-OV ER 5(EA.) 1.00
contracts for such projects with a contractort s)licensed pursuant to A
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft110.00 V TRACT NO. PARCEL NO.
❑ tum exemp under Sec. ,B.&P.C.lie Ibis WATER HEATER W/VENT 6.00
leas
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATIN _ 5.00
I hereby affirm that I have a certificate ofconsenl to sel Ginsure, D
Or a certificate of Workers'Compensation Insurance,cur certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lub.C.).
Policy No. Company '
Q ❑ Cetlified Copy is hereby furnished. FIRE SPRINK ENERGY,T-24
Z Z ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- O ORD. YE] N Y 0 NE]
~ vaPERMIT ISSUANCE 10,00
CC 1 CERTIFICATE OF EXEMPTION FROM WORKERS' - t1
' FLOOD zorvE L.u.c.
IL _ COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG. �� { e'G
CL O 1'rhis section need not be completed if the permit is for one TOTAL(7�sd Y❑ N� YA. N�
:D Z hundred dollars IS 100)or less.)
U 0 I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers Compensation Laws of California.
O y Dale - Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? eruption,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=11F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000GF.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the 309performance MICROFILM
Civ.C.nof the work for which this permit is issued(See. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EAT[NG U N IT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
Icertify that l have read this application and state that file above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
BOILER-COMP I3 H.P.or 100,000 B.T.U.) 6.00
♦, , ordinances and stale laws relating to building construction, and
n' hereby authorize representatives of this city to enter upon the 801 LER-COMP (Over 100,000 BTU)SEE FEE SCH. 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 in any way accrue against mid City in consequence of the PERMIT ISSUANCE 10.00
jilsartfulIg of this perhni MECH.CONT. LIC.NO. MECH.
e I' TOTAL TOTAL
matUTe of Applicant Contractor Dae
OFFICE COPY