12837 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING•PROJECT I DENTIFICATI ON PERMITNUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
�P a BUILDING-ELECTRICAL-PLUMBING-MECHANICAL ' 1'2837
OWNER'S - 'PLAN CHECK VALIDATION
""ME - CITY. ELECTRIC PERMIT FEE
PHONE
NAIVE OUTLETS-SWITCHES-RECEP ,10,00/1.00
.r.• NAME '
ep, C.NO. LIGHTING FIXTURES,- 10.00/1.00 1. ' '
ADDRESS D
ADs ^r' APPLIANCES 4.00
. .' DEss � PLIACES- , '
/' 3,J -ONE'1VQgaZf' / PANELS 10.00 DATE OF APPLICATION
ARCHITECT - PANELS'.(OV ER 200 AMP) 20.00
ENGINEER
PLAN CHECK FEE P.C.NO.
' p '• - - -
Lrc:NO. SIGNS TRANS. " 3,00 '
5,00 I. PERMIT VALIDATION
ADDRESS
.ADDRESS ENG. SPECIAL CIRCUIT '
,
'+ --ZIP° EMP.METER OR POLE INS. 20.00 A s
x
APPLICANT - _ MOTORS SEE FEE SDH. 'J� J/'1/'
ADDRESS + '- t t /7
SERVICE CHANGE 20.00 / .
I �
w
0 o LICENSED
CONTRACTORS DECLARATION
H I
a is U 1 hereby afOrn that 1 am licensed under provisions of Cha 9 ISSUANCE DATE
f-z w (con m,encing with Section 7000)of Division 3 of the Rusiness aful - .B ELECT. PLG. MECH.
-BLDG.
'6" Professions Code,and my license is in full for�•an eft c -
z. C,�s yL ee yyr
z Dy - ,License Class L' 3 � La;.Number SR A'f5 � -^ _ ❑ ❑
z a ❑
o f. Dale .Z� J 8^k� Contractor �_
` BUILDING PERMIT
¢
BE w ¢ OWNER-R UILDER DECLARATION INFORMATION
u o u ° MISC. REFER TO ORD
1 hereby affirm that I am exempt from the Contractor's License - VALUATION $/FT.
F u o J Law for the following reason:(Ser quires a,permit
to cod Professions PERMIT ISSUANCE 10,00
Code', e,demolish,
county which requirese pefmit tdto nRruel,alter, -
2 Q'Q improve,demolish,or repair any,lflmlum,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
D¢ requires the applicant for such panni Lto file a Signed statement that TOTAL PERMIT TO
n. w ca a- he is licensed pursuant to lite previsions of the Contractor's License
F i a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe t.8
i o Business and PRd sskmx Cndc)or that he is exempt therefrom and T PLUMBING PERMIT •FEE
the basis for the alleged exemption.Any violation of Section 7031.5 • ' STORIES TYPE CONSTR.
au by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).1: -
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE +' 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and'Ihe stfuctcm 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 so.FT.PtooR AREA TOTAL ACREAGE
himself'or through his own employees,provided that such improve-
mmol,are'not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.40UTLETS 6A0
or improvement is sold within one year of completion,the owner, GAS-EA.SYSTEM-OVER 4 IEA.) ^'2.00 BUILDING USE
builder will have the ale.). of proving that hm did not build or ith RES IND SON PB Ome.
prove for purpose of sale.).' INDUSTRIAL WASTE INTER. ', 30.00
❑ d as owner of the property,ant`projecty S, contracting with ❑ .. ❑ ❑ ❑ ❑
licensed contractors sod to construct the project La 7044,business LAWN SPRINKLERS-I INC 5.V.8. .6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an
tr owner of property who build,oactork licensed puand who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such Projects with a conlruc[orts)licensed pursuant In SEWER-SANITARY-STORM EA.20Oft/10.00
the Contractor's License Law. TRACT NO, PARCEL N0.
❑ 1 am exempt under Sec. ,B.&P.C.foi ons WATER HEATER W/VENIP6.00
reason JUW
Owner Date I WATER SYSTEM 00 ,ACC.DATE ACC.FILE NO.
WORKS RS'COMPENSAIION D17:CLA RATION _ WATER TREATING VFIR .00
I hereby affirm that I have a certificate of consent to self-insure, -
' or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3500,Iab.CJ. -
Policy No. - Company
❑. Certified copy is hereby furnislmd. FIRE SPRINK ENERGY T 24
Z Z •❑ Certified copy is filed with the iity inspection division. MISC.- •REFER TO ORD. $
O Aoffer,nt - - Y ❑ N❑ Y ❑ N❑
HN PERMIT ISSUANCE 1000
CERT .
IFICATE OF EXEMPTION FROM WORKERS' O FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0Prhis section need not be completed f the permit R fur one TOTAL V❑ N❑ W❑ N❑
hundred dollars(SIOD or)CSS.)
U O 1 certify that in the performance of the work for.which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, I shall not mnploy any person in any manner on as to
U, become subject to the IND kmrs'CCi]mpmnsatm Luws of Cu11if.min.
� ELI0. Dal y;Z-/�-JK Applicant fd,ss�'ILYN�rA - - .BUILDING
} m NOTICE TO APPLICANT': If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F Z emption,you should become subject to the Workers'Compensation APPLIANCE' 5.00 PLAN CHECK
Provisions of the Labor Code, youiomust forthwith comply with FEE
f CJ such pruvisns of this permit shall be deemed revoked. , AIR HANDLING UNIT(TO 10p000.F.M.) 4.00 -
CONSTRUCTIONLENDINGAGENCY 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 3097 Civ C .j nee of Btc work fur which this permit is issued(Sec. HEATING UNIVTO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name ELECTRIC
_ HEATING UNIT(OVER 100,000 B.T.U.)9.50 -
Lender's Address
I evrlify that I have read this application and stale(hat 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 to building construction, and BOILER-COMPO H.P.or 100,000 B.T.U:) 6.00
hereby authorize representatives of this city.W.,ntor upon the BOILER-COMP(Over 100,000 BTU)SEEFEE SCH. MECHANICAL
' above-mentioned property for inspection purposes. .
(We) agree to save, indemnify and keep harmless Die City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichCONST.TAX
` may in any way accrue against said City inconsequenceof the - PERMIT ISSUANCE -10.00 -
gmeding of this Pon .' _ y - MECH.CONT. LIC.NO. MECH. -
,/ TOTAL
tom.' l! 2•-/N=7i7 TOTAL
'St nature CAppleant/ ontractor. Date
OFFICE-COPY' '