12287 (2) APPLICANT TO FILL-IN INFORMATION WITHIN REDLINES - USE BALLPOINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION ' PERMIT NUMBER
..L.ING APPLICATION & PERMIT'
ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12287 GG n
�G697 SUAr 1 SC
OWNER'S , PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE "
ABRs A-I{A f'�77 P- .PHONE 9.176'130 ,
CONTRACTOR'S
NAME .. OUTLETS-SWITCHES-PIECED 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR ons
ADDRESS PPLIANCES-RESIDENTIAL 4.00 '
-
'p PHONE PANELS 10.00 DATE OF APPLICATION.
ARCHITECT - PANELS (OVER 200 AMPI 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO.. 'SIGNS TRANS. 3.00
ARCH.OR ENG. .PERMIT VALIDATION
aDDHESB SPECIALCIRCUIT 5.00 ,
ZIP TEMP.METER OR POLE INS. 20.00 G�
APPLICANT'S Q,I/ti''r
ADDRESS .• - MOTORS - SEE FEE SCH.
SERVICE CHANGE 20.00 L)
Woo LICENSED CONTRACTORS DECLARATION
a v 0I hereby affirm thatA am licensed under provisions of Chapter 9 - ISSUANCE DATE
z w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
w i Professions Code,and my license is in full force and effect. ,.y
o u0'w W License Class Lic.Number Vl- 1 , El
Date - Contractor Y�
¢ s J BUILDING PERMIT
¢ ¢ w¢ OWNER-BUILDER DGCLARA'HON �- INFORMATION
D a"OherebyMISC"- REFER TO ORD
La ; LL y Ifth affirm that I am exempt from the inco,a Contractor's License - VALUATION $/FT.
H Iso J Law for the following reason.(Sec.703 t,5,liusinessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter, �'
Q 4 p Impmve,demolish,or repair any Structure,pno,to its issuance,also ELEG CONTR. �LI C.NO. ELEC, a ( ,
¢ requires the applicant for such pertail to file a signed statement that ! ) - TOTAL CJD - PERMITTU
o. w m" he is licensed pursuant to the provisions c f the Contractor's License
i
Law(Chapter 9(commencing wit It Section 7000)of Division3 Gf the
< Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE r
¢ r the basis for the alleged exemption,Any violation of Section 7031.5 _ STORIES TYPE CONSTR.
iby any applicant for a permit subjects the applicant tots civil penalty gLTER-DRAIN.&VENT-WATER IEA.) 5.00
of 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 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 Corrrector 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.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- - GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
. - ments are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- " GAS-EA:SYSTEM,- 4(EA.) 200 BUILDING USE
builder will have the harden of proving that he diel not build or int- . RES IND CON 'PB Ome7
prove for purpose ofsale.). -' INDUSTRIAL WASTE INTER.- - 30.00
❑ I,as owner of the property,am exclusively 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:1'he Contractor's License Law does not apply
to an owner of property who huilds or improves thereon,and who LAWN'SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with it contractor(.)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCELNO.
❑ I am exempt under Sec. -s 134P.C.forthis WATER HEATER W/VENT 6.00 '
reason
�. Owner Date WATER SYSTEM 5.00 ? ACC,DATE ACG,FILE No:
WORKERS'COMPENSA'I'ION DECLARATION - WATER TREATING EQUIP. 5.00 -
I hereby affirm that I have a certificate of consent to self-insure, -
or,a certificate of Morkers'Compensation Insurance,or u certified ZONING ENG.SITE NO.
copy thereof(Ser.3800,Lob.C.L - - -
Policy No. Copany
Q m❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T$4
. Z Z ❑ Certified copy is filed with the city, inspection division. MISC.- REFER TO ORD.
O Applicant - - _ Y ❑ N❑. Y ❑ N❑
F rO PERMIT ISSUANCE ' ' 10.00
UJ - CIi R'fIPICCO1 OF SAI IO 1'INS FROM WORKERS' FLOOD ZONE A.L.U.C.
CL COMPENSATION INSURA NCI: - PLG.CONTR. LIC.NO. PLG
C . Y❑ ❑ Y❑ N❑
� (This section need not be completed if the permN it is for one TOTAL '
Z hundred dollars($100)or less
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,1 shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California. BUILDING
a Date Applicant ALTER OR ADD TO MECH. 5.00
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emplion,you should become subject to the Workers'Compensation APPLIANCE - - 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE '
5 such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY, AIR HANDLING UNIT(OVER 10000C.RM.) 6.00 SEISMIC FEE _
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work far which this permit is issued(Sec. MICROFILM
3097,Civ.C.). - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 `Q
Lender's Address _ ELECTRIC �-
I certify that I have read-this application and state that the above VENTILATION FAN (SINGLE) 4.00
L`. information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorim representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
a Eovememlaned 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 Said City in consequence of the. PERMIT ISSUANCE 10.00
granting f this ermiL MECH.CONT. - 3 LIQ N0. MECH.
TOTAL TOTAL
ng�n lure of Applicant/Contractor Date I
-
' OFFICE COPY - - ,