12237 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 12237
W
AODNBUILDING-ELECTRICAL-PLUMBING=MECHANICAL
_wm
OWry N' l p - PLAN CHECK VALIOATIONrvnmEOTY. ELECTRIC PERMIT. FEE- --rROM
PHONE 11 n
I.NTI
NAME crony UTLETS-SWITCHES-RECEP 10.00/1.00 O
NAME
'LIGHTING FIXTURES - 10.00/1.00
AOOOF Ess TOR's PPLIANCES-RESIDENTIAL 4.00 . DA�n,;{ x
E PANELS 10.00 DATE9AMIXTION
AR HI E T e�H� •,TQS t: PANELS MOVER 200 AMP) . 20.00 PLAN CHECK FEE P.0.NO.
OR
ENGINEER - - - JUL I 1 0
LIC.NO, SIGNSTRANS. 3.00 l 1 E-is
ANCN.OR ENG. y SPECIAL CIRCUIT -
5.01) PERMIT VALIDATION
AOOREES -
ZIP EM P.MET fTPRAPOL 1 S7 20.00 L`p
Cu @f�i[_IQ
'
APPLICANTSMOTORS SEE FEE SCH.
ADDRESS -
SERVICE C E 20.00
o o LICENSED CONTRACTORS DECLARATION
Ir:in U I'hereby afirr, that I wn licensed under provisiens of Chapter.9 ISSUANCE DATE
¢ w (wmmencing with Section ion 7000)of Division 3 of the Business and BLDG. ELECT. PLG. . sMECH:
asi. Professions Code,uI I license is Nin full for c �e f(c� y ❑ 1:1 ❑ ❑
z o m - License CP s Lic. umber -L1�-[-
Q H w Datc,y� Conlraaor -t.,A L-1 F[7 1(`' -
a Y s _ ` BUILDING PERMIT
¢ ¢w u - OWNER-BUILDER DECLARATION . INFORMATION
'W oil - MISC.- . REFER TO ORD ,t
3 LL w 1 hereby affirm that L s. exempt from the Contractor's License - VALUATION $/FT.
Fuo ¢ Law far the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
-' Code:Any city oremmty which requires a permit to construct,alter,at K¢a improve,demolish,or repair any structure,prior to its issuance;also ELEC.DDNTR. O LIC.NO.jy 1 1�5� ELEC.
m LL [equime tlteapplennt(or such permit to file a signcA slnimnent that T,� -Cxs-.U_ J 1] TOTAL , PER IT TO -
w' Y
6 w he is licensed pursuant to the provisions of the Contractor's License ep
-
H zi Law.(Chapter9(commencing with Section 7000)of Division 3 o"the
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ m the basis for the alleged exemption.Any violation of Section 7031.5 - '
STORIES TYPE CONSTR.
e_ ; _ by any applicant for a permit subjects the applicant toacivilpenalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
- - of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE' 4.00 OCC.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,AR EA,COND. 5.00 _
Code:The Contractor's License Law does not apply to an owner of
property who buildsor improves thereon,and WHO docs SIICh work FIXTURES-PER TRAP .5.00 9G.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided]het such improve-
mentsarenotintendedorolferedforeale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6,00
or improvement is sold within one year of completion,the owner-
GAS'-EA.SYSTEM-OV OVER 41EA.1' 2.00 BUILDING USE
;N�fyC;)JI builder will have.the burden of proving tithfhediJ not build or im- � - RES IND CON PB Omer
prove for purpose,of Sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner ofthe property,am exclusively contractingwith 11 1:1 El 1:1F-1licensed to contractors construct the project(Sec.7044,business LAWN SPRINKLERS=1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
r and Professions Code:'I')in Contractors 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 pursuant to SEWER-SANITARYV-STORM EA.200ft/10.00
the Conir5ctor's License Law. - TRACT N0. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.I'ar this WATER HEATER W/VENT 6.00
reason
Owner Dote 'I WATER SYSTEM, 5A0 ACC,DATE ACC.FILE NO.
`
WORK 1:RS'COMPENSATIONDECI:ARA1ION WATER TREATING EQUIP. 5.00
I hereby affirm that'I have a certificate ofennsent to self-insure. - - ZONING ENG.SITE N0.
- or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
Q O Certified copy isbereby furnished. FIRESPRINK ENERGY T 24
Z Z. ❑ Certified copy is fled with the city inspection division. MISC.- .REFER.TO ORD.
O Applicant ' Y❑ NO 'Y ❑ N❑
~ rn - 4SSUANCE ' 10.00 FLOOD ZONE A.L.u.C.
CC CE RTIFICAI'17 OF EXi;M PTION FROM WORKF.RS' PER
LU _ .COMPENSAT ION INSURANCE PLG.CONTR. _ LIC.NO. PLG.
C' 0 (This section need not be completed if the permit is'far one TOTAL Y❑ N❑ Y ❑ IN
D Z hundred dollars($100)or less.)
- L) 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 stroll not employ an person in any manner so as to -,
U becom`,�dp1 eWurkerf ens: a'ornia.
O w DateJ�SJL7iJ.Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICETOPPLICANT: If,after making tin ertificate of Ex-
F Z emption,you should become subject ro the Wor o'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of line labor Code, YOU must forthwith comply wine FEE
r U such provisions or this permit shall be deemed revoked.. AIR HANDLING UNIT(TIC-10P OC.F.M.) 4.00
colvsiaucfloN LENDING AGENCY AIR HANDLING UNITIOVER 10=CF.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction Icnding agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. - MICROFILM
3097,CmC.). HEATING UNIT(TO 100,000 B.T.U.) A-00
Lender's Name H EATI NG UN IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC S r0
I certify In have read this application and slate that the above 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 BER-COMP(3 H.P.or 100,000 B.T.U.) .6:00
C+x f hereby authorise representatives of_this city to enter upon the BOILOILER-COM P,IOver 100,000 STUB SEE FEE SCH. MECHANICAL '
above-mentioned property for inspection purposes. _
(we)I 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 said City in consequence of the PERMIT ISSUANCE 10.00
granting of this permit MECH.CONT. LIC.NO.. MECH.
yqgy . 'oT"` TOTAL O
Signature of Applican ontractor Dale I D
OFFICE COPY -