12460 (2) "APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT FEN ONLY
VU I LDI NG P.ROJE6T I DENTI FICATI ON PERMIT NUMBER
BUILDING
APPLICATION & PERMIT 12460
AOOR ss BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
og
I ER'S PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE a
�I PHONf
/ CON ACT R'S
UTLETS-SWITCHES-RECEP 10.00!1.00 76 D IIJ
_7� ILIGHTING FIXTURES 10.00/1.00
DGNT ACTOR'S PPLIANCES-RESIDENTIAL 4.00
A DRESS
PRONG C� _ PANELS 10.00 DATE OF APPLICATION
CHIcrCIA �`,� •t� _ PANELS (OVER 2010 AMP) 20.00 PLAN CHECK FEE .c.No.
ENGINEER
UC.NO. SIGNS TRANS. 3.00
ARCH,OR ENG. 5,00 �Ef1r�j.J(ALIDATION'
ADDRESS ' coirb E. SPECIAL CIRCUIT �„ VV
ZIP t EMP.METER OR POLE INS. 20.00
noliaessTs MOTORS SEE FEE SCH. ff�?�-�[� AP 7
SERVICE CHANGE 20.00 y+ss��/ j\,q���'/,/
woo LICENSED CONTRACTORS DECLARATION . CIL) OI yr yrvQl
¢ v u I hereby affirm that 1 am licensed under provisions of Chapter 9 - ISS ANCE DATE
wK uWAi (commencing with Section 7000)of Division 3 of the Businen and t BLDG. ELECT. PLG. MECH.
F D z_ Professions CodWy�d��my been.i in full for ' td If I
Oz u y/, License Clan 24S`Lic.N blur ' �[1; 9 ❑ ❑ ❑
0 Da='=-7 �-. Tri Contractor /.5 .l s n
< y -r BUILDING PERMIT
¢ ¢w o OWNER-BUILDER D17CLARATION INFORMATION
F wLL 0 MISC.- REFER TO ORD
H I hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
H u_Oj Law for the following reason.(Sec.703L5,Businessand Professions PERMIT ISSUANCE. 10.00
Code Any city or coun ty which requires apermit to construct,alter, 1/AL.
U
2 ¢ ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. )V
u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$w he is licensed pursuant to the provisions of the Contractor's License
F z Q Law(Chapter 9(commench,with Section 7000)of Division 3 oftbe
4 O Business and Professions Code)or Into he is exempt therefrom and CITU. PLUMBING PERMIT FEE
¢ F the basis for the alleged exemption.Any vinlativa of Section 7031.5 STORIES TYPE
CC
Business
i ; _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the properly,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 n not
intended or offered for sale (See. 7044, Businen and I'mfenions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cade:The Contractor's License Law does not apply to an owner of
,4 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
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 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 ire- RES IND CON PB CO.,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30:00 ❑ F1 El El 11❑ 1,as owner of the properly,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 Profession,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 contractor(%)licensedpursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dam WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a ceRifeate of consent W elf-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See 3800,Lab C.).
Policy No, Company
O ❑ Cerlilmd copy is hereby urnished. FIRE SPRINK ENERGY T-N
Z >� ❑ C iced c ry is. D uu th cit " spa 'an division. MISC.- - REFER TO ORD. v N v N
AppGca ❑ ❑ ❑ ❑
QN CE I II CATE OF E X EM PTI ON FROM WO R K It RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.I_U.D.
LU >_ COMPENSATION INSURANCE PLG.CONTR. LIC.N0. PLG.
0 (This section need not he completed if the permit is for one TOTAL Y❑ N❑ Y [3N❑
Z hundred dollars IS 100)or less)
U O1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
TL F mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
O w Date - Ap - BUILDING /g'3
PBrant ALTER OR ADD TO MECH. 5.00 /
F_ rasa NOTICE TO APPLICANT: If,after making this Certificate Ex
F Z emption,you should become subject m the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions io the Labor Code, you must forthwith comply with J
U such provision or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 4,00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNTT(OVER 10=C.EM.) 6.00 SEISMIC FEE Qy
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work fIor which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Cis C.).
Lender's Name HEATING UNIT I0 VER 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 BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
s ordinances and state laws relating to building construction, and
hereby authorize representatives or this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
< above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmlen the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, cost.% and expenses which CONST.TAX
may in any way acerae against said City in consequence of the PERMIT ISSUANCE 10.00
S gofthupermT.it. MECH.CONLIC.NO. MECH.
i Z- TOTAL TOTAL
atumof pp ant/ ntactor Date
OFFICE COPY