12956 (2) 70 7-2//J
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE ALL
POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 12956
- ADDRESS BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
by / 3L
OWNER'S PLAN CHECK VALIDATION
U� NAME OTY. ELECTRIC PERMIT FEE
rRACTDRs UTLETS-SWITCHES-RECEP 10.00/1.00
N E
Ic.n LIGHTING FIXTURES 10.00/1.00
corv4cTa ' APPLIANCES-RESIDENTIAL 4.00
•OGREmSS
pqp -70 IPANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc,NO SIGNS TRANS. 3.00
ARGH.DR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADOREss
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS D X � a MOTORS SEE FEE SCH. /7
A DREsszC/�^�"
SERVICE CHANGE 20.00 �
w o o LICENSIiD CON'I'R ORS DECLARATION - - •�
a, v 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w fe inni (commencing with Section 7000)of Division 3 of the Business and BLOG. ELECT. LG M H.
Z O N i 1, So s ode,u�0 I nt fce s 9 1 y tub roIy lty.`L ❑ t.
Q H w Dnlc Conlrac�
< y 4 'y, BUILDIN PERMIT 14
¢ ¢w 4 OWNER-BUILDER DECLARATIONY -�/' INFORMATION
o> c' MISC.- REFER TO ORD
X
U.N 1 hereby affirm that I an exempt from the Contractor's License VALUATION 3/FT.
D 4 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
LLL m -I Code:Any city or county which requires permit to construct,alter,
¢ e,¢20 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w$u he is licensed pursuant to the provisions of the )Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division3ofthe
f E o Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢ I- the basis for the alleged exemption.Any violation ol'Sectiou 7031.5 STO S YPE CONSTR.
dg� by any applicant]or a permit Subjects the applicant toa Civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).)'.
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their Sale compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOT AL ACREAGE
himself or through his own employees,provided that such improve-
mentsare not i
mended oroffered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
i or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively Contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to Construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlractor(s)licensed pu¢uanl to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
D I am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILENO. .
WORKIiRS'COMPIiNSATION DECLARATION WATER TREATING EQUIP. 5.00 '
I hereby affirm that I have a certificate of consent to sell-i.sure, ZONING ENG.SITE NO.
or a certificate of Workers'Com pe o Insu Wice,ea certified
cop there jf$},.e' 3�00t Lab,C. f
pony
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z 2 3y Ger{ ed II d /v' c}'� S R iv MISC.- REFER TO.ORD. ❑ ❑ ❑ ❑
A plica. L ` L Y N Y N
F- y PERMIT ISSUANCE 10.00 •(�
CERTIFICATE OF EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
IL J COMPENSATION INSURANCEy}G.CQNTR. 'rlo.�yG.al PLG. 7/D �•y�
CL 0 (This section need not be completed if the permit is for one f�(� / .J TOTAL,20a o Y❑ IN Y ❑ N❑
Z) 2 hundred dollars(5100)or less.) FEE SUMMARY
U O 1 certify that in the performance of the work for which this per- TY. EC NICAL PERMIT FEE
LL H mit is issued,I shall not employ any person in any manner so as to
O W become subject to the workers'Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of F.x-
r ? eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. 2 AIR HANDLING UNIT(TO I0=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOAOOC.EM.) 6.00 SEISMIC FEE
I hereby affirm that (here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance f the work for which this permit is issued(Sec MICROFILM
3097,Cie C.). �? ` HEATING UNIT(TO 100,000 B.T.U.) 5.00
Lender's Name/ HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that 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-COMP(3 H.P.or 100,000 B.T.U.) 6.00 /
hereby aurhoriee representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL 3e�
above-mentioned property for inspection purposes.
MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in cousegace of the '
ingot this perinil. CR LIC.NO. MECH.
/0 �� TOTAL )� TOTAL
gilarture of Applicant[ContfaZDar D. o� t
OFFICE COPY