12816APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
'
-
PERMIT NUMBER
BUrLDI NG PROJECT DENTI FICATION
I
APPLICATION & PERMIT
BUILDING .
ADDRES
1S/{ 16// / //n, -
"/ LGD9NOn A
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
12 816
OWNER'S
NAME %J
W U �(� PHONE
gTy, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTORS
NAME
UTLETS-SWITCHES-RECEP 10.00/1.0
LIGHTING FIXTURES 10.00/1.00 Id -
LIC. NO.
CONTRACTORs-
ADDRESS
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
PHONE
DATE OF APPLICATION
ARCHITECTPANELS
OR
ENGINEER
LIC, NO,
(DYER 200 AMP), 20.00
PLAN CHECK FEE P.C. NO,
SIGNS TRANS. 3.00
ARCH. ORENG. -
ADDRESS
. ZIP
SPECIALCIRCUIT S.DD
PERMIT VALIDATION
EMP. METER OR POLE INS. 10.00
APPLICANT's .'
ADDRESS
MOTORS CH.
SERVICE CHANGE -
LICENSED CONTRACTORS DECLARATION
IUUW
I hereby affirm that 1 am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect
License Class Lic. Number
BLDG.
❑
ELECT.
PLG.
❑
MECH.
❑
Dale Contractor
BUILDING PERMIT
OWNER -BUILDER DECLARATION
I hereby affirm that 1 so exempt from the Contractor's License
Law forthe following(See. Professions
Any reg03L5 perminess t to
Code: Any city or county which requirese permit to construct,, lter,also
Improve, demolish, or for sir any permit toff prior t0 its issuance, x150
requires the applicant for such permit [o file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
INFORMATION
MISC.- REFER TO ORD
VALUATION
PERMIT ISSUANCE 10.00 Q. --
ELEC. CONTR. LIC. NO.
rC1
TOTAL
TOTAL �
PERMIT TO
�-C G7
QTV. PLUMBING PERMIT FEE
1
STORIES
TYPE CONSTR.
ALTER-DRAIN-WATER(EA.) 5.00
by any applicant for a permit subjects the applicant toacivilpenalty
of not more than five Imndred dollars ($500).):
'❑ 1, as owner of the property, or. my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, ARE; COND. 5.00
Code: 'the Contractor's License Law does not apply to an owner or
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-
mentsareno( intended or offered for sale. IC however, the building
GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
licensed Contractors to Construct the project (See. 7044, Business
GAS - EA. SYSTEM - OVER 4 IEA.) 2.00
BUILDING USE
RES . INDCON PB Other
❑ E] ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS -I 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 builds or improves thereon. and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractods) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 2001ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
0 l am exempt under Sec. ,B.&P.C. for this
reason
_
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WORKERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE N0.
Copy thereof (Sec. 3800, Lab.C.L
Policy No. Company
❑ Certified copy is hereby furnished.
❑ Certified copy is fled with the city inspection division.
Applicant
FIRE SPRINK
y ❑ ry ❑
ENERGY.T 24
' Y ❑ N ❑
MISC.- REFER TO ORD.
CERTIFICA'MOF I XEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.0 C.
PLG. CONTR. - _ ❑C. NO.
PLG.
TOTAL
" COMPENSATION INSURANCE
(This section need ,or be completed if the permit it for ofe
y ❑ N ❑
v ❑ N ❑
QTV MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars(SI00) or less,)
I certify that in lire performance of the work for which this per-
mil is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Dale Applicant
NOTICE TO APPLICANT: If, He, making this Certificate of 1'-x--
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or (his permit shall be deemed revoked.
BUILDING
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10=CF:NL) 4.00
AIR HANDLING UNIT(OVER 10=C.F.M.)6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
I hereby affirm that there is a constructlov lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.CJ.
Lender's Name
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UN IT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lender's Address
I certify that I have read this application and stale that the above
information is correct. I agree to comply with all city and county
ordinances and stare laws relating io building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER-COMP13 H.P. or 100,000 B.T.U.) 6.00
SO1LER-COMP(Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby aulhorim representatives of this city to enter upon Ore
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
Fifty in any way accrue against said City in consequence of the
MISC. - REFER TO ORD.
CONST. TAX .
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO. MECH'
TOTAL .
TOTAL
granting of this Iselin'
ignaturc of Ap cant/Contractor Date'
OFFICE COPY