12759 (2) APPi ICANT,TO FILL IN INF MATION WITHIN REDLINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
J. BUILDINGPROJECT IDENTIFI oN 'APPLICATION & P IT
mint-DING 12759
A...Es5 ///��� _
_ //. ,� q BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
0 Ell G PLAN CHECK VALIDATION
• "9M`E_� V QTY. ELECTRIC PERMIT _ FEE
PHON ar30 r
TRA OR's
NAME'/ UTLETS'-SWITCHES-RECEP 10.0011.00
LIGHTING FIXTURES _ 10.00/1.00
CONTRACTOR R's • r - APPLIANCES-RESIDENTIAL 4.00
b0 E(JZ ONE 6 33< 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
-' ADDR
RCO OR ENG. - -• SPECIAL CIRCUIT 5.00 . PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS ,MO
ORETORS SEE FEE SCH.
AD
• •Q Pd( SERVICE CHANGE 20.00 . - -. .✓,i/ 0 /
w
00 LICENSED CONTRACTORS DECLARATION - -
Q U U I hereby affirm that I am licensed under provisions Of Chapter 9 ISSUANCE DATE
y G n' (commencing withSection7000)of Division 3 of the Business and - BLDG. ELECT. I PLG. MECH.
H w i Professions C lyly license is in full far a d 'fee ❑ ❑ ❑
zNumber
Q y H )alC s��[q f.'OmtmCtOr
a x s LI � Y BUILDING PERMIT
OWNER-BUILDER DECLARATION - INFORMATION
woa " ' MISC.- REFER TO ORD
LL H I hereby affirm that I am exempt from the Contractor's License VALUATION- $/FT.
F u o¢ ' Law for the following mason. 7031.5,Business and Professions PERMIT ISSUANCE 10.00
m a Code:Any city or county whiCumcniresu permit in construct,ul[eq
re 2 ¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. - ''p.LIC.NO. ELti
D LL requires the applicant for such permit t0 file a signed statement that TOTAL PERMIT TO
e w m he is licensed pursuant to the provisions of the Contractor's License JAL y�
Law Chapter 9(commencing with Section 7000)of Division 3 of the / O
¢ Business and Pro@ssions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT -FEE
G STORIES TYPE CONSTR.
M the basis for late alleged exemption.Any applicant
t orSection 7031.5 _
n ;� by any applicant faro permit subjectsthe$500).licam ta.civil pamlty ALTER-DRAIN-&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(55001.): '
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the st iucture is not
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AR EA,CON D. '5.00
Code:The Contractor's License Law does not apply to an owner of -
propertywhobuildsorimprovesthereon,and who does such work FIXTURES;PER TRAP 5.00 SO.FT.FLOORAREA TOTALACREAGE
himself or through his own employees,provided that suclrimprove-
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 cnmpleti m'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 int RES ' IND CON PB Dmer'
prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property, in ek,lusivcly contracting with - ❑ ❑ ❑ ❑ ❑
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 buildi or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with ticonlNemds)licensed pursuant to
the Commctor's License Law. . SEWER-SANITARY-STORMEA.'200ft/10.00 TRACT NO, PARCEL NO.
❑ lumexemptunder Sea ' ,it&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date - WATER SYSTEM - 5.00
- ACC.GATE ACC.FILE NO.
WORK ERS'COMPENSAT10N DECLARATION WATER TR EATING EQUIP. .00
1 hereby affirm that I have a certificate of consent to self-insure, .
ora certificate of Workers'Compensation Insurance,or a certified ZONING ENG:SITE NO.
copy thereof(Sec.3800,Lab,C.)./1- .4y A
Policy No. Cmnpany Q((J_LfJ
❑ Certified copy ishreby furnished. - FIRE SPRINK ENERGY T24
Z 2 ❑ Certified eoNfil s• 'ty inspection division. MISC.- REFER TO ORD.
p Applicant_a' v❑ N❑ Y ❑ No
~ 0 - PERMIT ISSUANCE - -10.00 Q FLOOD ZONE A.L.U.C.
` cc CE RTI FICATE 017 EXF MP1'ION FROM WORKERS'
L 1 COhIPENSA7'ION INSURANCE PLG.CONTR. LIC.NO. PLG. �J
.EL 0 ('1'[iis section need not be completed if thepermitis for one _ _ TOTAL O\ Y N
❑ ❑ Y ❑ N❑
hundred dollars(5100)or less)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE, FEE SUMMARY
LL F mit is issued,1 shall not employ any Person in any manner so as to -
U become subject to the Workers'Conmenmtion Laws of California.
0 Q. Date Applicant - ALTER OR ADD TO MECH. - •• ' 5.00 BUILDING
} W' NOTICL',TO APPLICANT: If,after making this Certificate of Ex.
? emption,you should become subject to the Workers'Colnpensulion APPLIANCE ' 5.00 PLAN CHECK
provisions of the Labor Code, you most 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 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the 3097 eCiv.0 ante of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM '
Lender's Name HEATINGUNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I Certify that l have read this application and state thatthe.hove VENTILATION FAN (SINGLE) 4.00
'information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state,laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this cityto enter upon the
above-mentioned property for inspection purposes. ,BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(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 un way accrue,against said City in consequence of the PERMIT ISSUANCE 10.00
granting o this p mIL MECH.CONT. LIC.NO. MECH.
`b ��/L ('}'_/_9 t7. TOTAL TOTAL
1 Signature° can ontructor • Uate 4 -
.OFFICE COPY - /1