12732 'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION • PERMIT rvukIBER
aDILOINc APPLICATION & PERMIT ^ n
7d AooREss G G
O }�/r lj1LDING -ELECTRICAL-PLUMBING-MECHANICAL
/V PLAN CHECK VALIDATION
i;j-F• "Alda TV. ELECTRIC PERMIT FEE
PHONE _
r. CON RAc ORS UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
sec.No. Q6 LIGHTING FIXTURES 10.00/1.00
DTRADrons ' ' LY � -RESIDENTIAL 4.00
DRESS
PHOnE PANELS 10.00 DATE OF APPLICATION
ARCHIT9 PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3,00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICT
ANS MOTORS SEE FEE SCH.
ADDRESS A
SERVICE CHANGE 20.00
Woo LICENSED CONTRACTORS DECLARATION
ac v u 1 hereby atlinn that I am licensed under provisions of Chapter'9 UANCE oATE
w< vat (Commencing with Section 7000)of Division 3 of the Businessand B CT, PLG. MECH.
F N z Professions Code pad my license is in full force d feet. ❑ ❑
iso - LicenseClass_p-Z Lia Numtre � ❑
- u, H w Date/ �> �- S ZContractor I PERMIT
F
wa OWNFRTUILDER DECLARATION INFORMATION
REFER TO ORD
E
3 u y I hereby affirm th5t I am exempt from the Contractor's LicenseMISC.-
u 04 Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
-NJ Code:Anycityorcounty which nquiresa permit to cons"M alter,
re ra <2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC NO.
O LL requires the applicant for such pemli[to file a signed statement that TOTAL ^ PERMIT TO
K
he is licensed pursuant to the provisions of the Contractor's License
r z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 Business and Professions Code)or that he is exempt therefrom and [BACK
PLUMBING PERMIT FEE
0 the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant fora permit subjects the applicant loo civil penaltyALTER-DRAIN -WATER (EA.) 5.00
of not orore than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their Pule compensation,will do the work•and the strcture rs not
Intended or Offend for sale (Sec. 7044, Business and ProfessiosDRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractors License Law does not apply to an owner ofproperty who builds or improves thereon,and who does such workFIXTURES-PER TRAP 5.0050.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improvesmems are not Intended or offend for sale.If,however,the buildingGAS-EA.SYSTEM-11NC.40UTLETS 6.00
or bnprovement is sold within one year of completion,the ownerGAS-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 Oma
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,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 does not apply
I.ae owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractoos)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B&PC.for this WATER HEATER W/VENT 6.00
Mason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EOUIP. 5.00
I hereby affirm that I have a certificate of consent to sell-insure, ZONING ENG.SITE N0:
or a certificate of Workers'Compensation Insurance,or u c fife)
copy thereof(Sce.3800,Lab C.). s e
Policy No. Company /�.r o,_i ZA cis.Pis.B,
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY Tia
Z Z / O CeStifl�Q�copy u filed with }hc c- spmtion division. qMEISCEE.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
O<' Applicam lt�f2c iaL
Cc CERTIFICA'fEOP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. y❑ "❑ v F] NEICL a (This section need not be completed if the Permit is for one TOTAL
::) Z hundred dollars(S 100)or less.)
U 0 I certify that in the perfunrance of lire work for which this Per. OTY MECHANICAL PERMIT FEE FEE SUMMARY
UL F mit 6 issued,I shall not employ any person in any manner so as to p
O w become subject to the Workers'Compensation Laws of Califomia. BUILDING 3�J sa
Date Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If,after making this Certilicale of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M0 4.00 pp
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=CEM.) 6.00 SEISMIC FEE �p'U,
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the porfommoce of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.)0.50 ELECTRIC
Lender's Address
vf'r�. I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.DO
� information is correct. I agree m comply with all city and coumy - PLUMBING
+ BOILER-CONR(3H.P.Or100,000B.T.U.) 6.00
ordinances and state laws relating to building construction, and
j p hereby authorize representatives of this city to serer upon tho BOILER-COMP IOxer 100,1100BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep humless the City of 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 coRsequenLro of the
granting of this permit / MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL �7 2"X7
N
o ppGca ontreclor Date
OFFICE COPY