12284 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 12284
A0 EE7
?/SS
Q Ze eLvod BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - ' PLAN CHECK VALI DATION
TY. ELECTRIC PERMIT FEE
;� L��l Cr /7UPHDNE S=
CONTRACTOR S
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
uc.No, LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 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 �
ARCH.OR ENG. SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ADDRESS
ZIP rEEMP.METER OR POLE INS. 20.00 n /
avvucaNrS MOTORS SEE FEE SCH. � L/f�.,"_„/{..--/
ADDRESS Q
SERVICE CHANGE 20.00 /V/I q
M D LICENSED CONTRACTORS DECLARATION I
< v 1 hereby affirm that I mit licensed under provisions of Chapter 9 ISSUANCE DATE
H z ac (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r H Z Professions Code,and my license is in full force and effect r-I
Z o m - License Class Lic.Number-
2
umber o Z - w Date Contractor
a x 4 BUILDING PERMIT
Q.w OWNER-BUILDER DECLARATION INFORMATION
aoa MISC.- REFER TO ORD
X I hereby affirm that I am exempt from the Contractor's License
ao¢ Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION SIFT.
- Code:Any city or county which requiresupermitro construct,alter,
Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i-LO u requires the applicant for such permit to File a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
Fzi Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe Mem{
4 Business and Professions Code)or that he is exempt therefrom andQTY. PLUMBING PERMIT FEE
r$ the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
a ; - by any applicant for a permit subjects the applicant toe civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,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,GOND. 5.00
Code: The Contractor's License Law does not apply to an owner of I,
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-
Huntsarenotintendedoroffered for sale.If,however the building ' GAS-EA.SVSTEM-11NC.40UTLET$ 6.00
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 im- 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 ASSES50HS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with,a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&RC.1 for this WATER HEATER W/VENT 6.00
reason
Owner at L-� WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK F.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
' Z Z ❑ Certified copy is filed with.the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ No
CCN CERTIFICATli 015 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
DJ > COMPENSATION INSURANCE PLG.CONTR. ❑C.NO. PLG.
CL 0 (This section need not be completed if the permit is for One TOTAL Y❑ N❑ Y❑ N❑
::) Z hundred dollars IS 100)or less)
U.O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,I shall not employ any person in any manner so as to
O L) become subject to the Workers'Compensation Laws of California. BUILDING
LU Date-Applicant ALTER OR ADD TOME 5.00
} to NOTICE. TO APPLICANT: If,after making this Certificate of Hx-
F ? emptlon,you should become subject to the Workeri Compensation y qpp LIANCE 7�-�•� 5.00 _- PLAN CHECK'
provisions of the Labor Code, you must I'nrthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 .M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING U IT(OVE .) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST I D 5.00
the performance of the work for which this permit.is issued(Sec. MICROFILM
3097,Civ.C). A IT( 10 0 .T.U.) 8.00
Lender's NameE ING 10 R 00,000 B.T.U.19.50 ELECTRIC
Lender's Address
I certify that I have read this application and slate that the above E IL?C 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 SOI -COMPI3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 10,000 BTU)SEE FEE SCH. MECHANICAL Q
above-mentioned property for inspection purposes. �.�
'(We) agree to save, indemnify and keep harmless the City ofMISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may Ed any way accrue against mid City in osequence of the PERMIT ISSUANCE 10.00
graofls / iJ�/ MECH:CONT. LIC.NO. MECH. �� TOTAL
permit.
rjll-j 7 G^A TOTAL
Signature of pphant/C ntract� or DPotc D.b
OFFICE COPY