12605 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PENONLY
BU LDI NG PROJECTIDENTIFICATION PERMIT NUMBER
'OILDN' CjZ4 (- APPLICATION & PERMIT
DORa /30D BUILDING-ELECTRICAL-PLUMBING-MECHANICAL _ 12605 GC0C
OWNERS
PLAN CHECK VALIDATION
NAM ITB 7zrL QTY. ELECTRIC PERMIT FEE
PHONE,
CONTRACTOR'S
NAM � .- ,1_ „_,, -SWITCHES-RECEP 10.00/1,00 -
LIGHTING FIXTURES. r 10.00/1'.00
CONTRACTOR'S 'yppLIANCES-RESIDENTIAL ,4.00
A 7 i AJ,7T" S7 Z9�Qilal
PHONE PANELS 10.00 PATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. - SIGNSTRANS.' 3.00
f•. AARCH OR DDRESS E"O SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 _J -
APPLICANTS - MOTORS - 'SEE'FEE SCH. !�I(./„•'._I'r•`^
ADDRESS
SERVICE CHANGE 20.00 - / /C
woo LICENSED CONTRACTORS DECLARATION W/10 /8
r /(U(0
a u C, I;hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w¢ i (commencing with Section 7000)of Division 3 of elm Business and IBLOG. ELECT. PLG. MECH.
r N i Professions Code ' dy��lieense is in full force ar�fglfyc�Q, ,x•
O m w 0-
S,
License Class_ t' {cS,�Lic.Number_ "� � � El
Date Contractor
a S, s _aE -E BUILDING PERMIT
a p1w u OW )ER Df:CLA JAIO �Ix INFORMATION
X ;LL N I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION $/FT.
Fu O,J Law for thefullorcountywhih(Sec.
requires 5,ermit to
Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. - LIC.NO. - ELEC.
DLL requires the applicant for such permit to file a signet)statement that TOTAL • PERMIT TO
E
z to he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 D, Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
It )- $ the basis for the alleged exemption.Any violation of Section703L5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not in..than five hundred dollars($5001):
❑ I,as Owner of the property,or my employees with wages is BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not '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 does not apply to an owner of - -
,� property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 sO.PT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarelet intended or offered for sale.If,however,the building GAS-EA.SYSTEM-l1NC.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 riot build or inn- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ 1,as owner of the properly,air exclusively ttortroclieg with ❑ ❑ ❑ ❑ ❑
licensed comractors.to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
v and Professions Coda 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 Pursumn to SEWER-SAN EA.200ft/10.00
the Contractors License Low. TRACT NO. PARCEL NO.
❑ I am exempt under See. • ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason -
.Owner Dare WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK Ii RS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Com per at ou Insurance,or: ' ,tifi,d ZONING ENG.SITE NO.
copy Ihe.of(Seo.3600,Lab.C.l. � ���1'By�G -
I'olicyNo. Company J`rL
0 ❑ Certified copy i Iereby IF fished. - _ - FIRE SPRINK ENERGY T;24
Z Z ❑'Certified tiled Ih the city inspection division. MISC. REFER TO ORD.
0 Applicant Y ❑ N❑ Y ❑ 'IN❑
rA CERTIFICATIiO F;) ! ' ' N FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE AL.U.C.
ILI J COMP) TION INSURANCE - PLG.CONTR. LIC.NO. PLG.
CL Z (This section need not he.completed if the pennil is for one TOTAL Y❑ N❑ Y ❑ N❑
hundred delta.(S 100)or leo) '
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
UL F mit is issued,1 shall not...ploy any Person in any mmencr so as to
0L) become subject to the Workers'Compensation Laws of California. BUILDING
y
[)are-'Applicant - ALTER OR ADD TO MECH. 5.00
} rn NOTICE TO APPLICANT: if.after making this Certificate of Ex-
F ? emprion,you should become subject to[lie Workers'Compensation APPLIANCE in 5.00 PLAN CHECK
previsions•ol' the,Labor Code, You forest forthwith comply withDO FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNI 1Q0000F.M) ' 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNI ( E 1 Q.EM.I 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HO ITH-DUCT) 5.00
the performance of the work.for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 1 .) 8.00
Lender's Nome HEATING UN IT 100,000 B.T.U.19.50
Lender's Address ELECTRIC
'1 Certify that I have read Otis application and state that the above VENTILATION FAN (SINGLE) 4.0 .00 - . •_
information is Correct. I agree to comply with all city and county Z PLUMBING
. ordimmets and state laws relating to building construction, and BOILER- H.P.or 100,000 B.T.U.) 6.00 1%.00 '
•hereby authorize representatives of this city to enter upon tire
above-men (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 PERMIT ISSUANCE 10.00 p.Cp CONST:TAX
may in any way accrue against said City in consequence of the
granlin GttIRllermit. MECH.CONT. LIC.NO. MECH.
�p TOTAL TOTAL
SignatureA=59tractor Date inn OO
OFFICE COPY