12690APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
12690
BUnLOING
A R 5 '��
OWNERS-
NAM
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NE
NOMTR CTORs
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
q�LIc. NO.
DATE OF APPLICATION
,O OR's
oDREss
30 l'
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT
DR
ENGINEER
Sac. NO
PANELS 200 AMP) 20.00
PLAN CH P.C. NO.
ISIGNS TRANS. 3.00
ADR, ENG.
ADDDRESSSS
SPECIAL CIRCUIT 5.00
�� 7N
TEMP. METER OR POLE INS. 20.00
ZIP
urlj yj A„� •. -
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
f0fessi ns f.'od n 'cense is in full force and effect
License Class Lic. Number
BLDG.
❑
ELECT.
ED
LG MECH.
Daft Contractor
BUILDING RMIT
OW aI R DECLARATION
ch I em exempt from the Contractor's License
I hereby affirm thust am exam
Law forthefu0oromentywhicSec.7iresa itocnd Professions
Code: Anycolishcountywhiny structurepermit ritoconsuance,alo
improve, demolish, or repair any structure, prior to its issuance, also
INFORMATION
MISC. - REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO.
ELEC.
requires the applicant for such permit to file a signed smor's Li that
he is licensed pursuant to the provisions of the Contractor's License
TOTAL
PER
QTY. PLUMBING PERMIT FEE
of Division 3 of the
Law (Chapter 9 (commencing wish Section is exempt
Business for Professions Come) or that he is exempt therefrom and
basis for the alleged exemption. Any violation otoocli0n
STOR ES
TYPE NSTR.
malty
by any applicant fora permit subjects the applicant too civil penalty
by
of not more than five hundred dollars (EE00).):
ALTER -DRAIN & VENT -WATER (EA.) 5.0(
'
❑ I, 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, AR EA, 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
SO. FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve
meets 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-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUIL ING USE
RES IND PB Omar
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESS 5 CEL NO.
licensed contractors to construct the project (Sec. 7044, Business
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 comm<tortsl licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec.., B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKF.RS'COMPENSA'TION DECLARATION
1 hereby affirm that I have a certificate ofconsent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof fSee. 3800, Lab.C.).
�I Policy No. Company
FIRE SPRINK
ENERGY T-24
Certified co is hereby forms)
J❑
❑ Certifmdypy -a fi d w cit i spection division.
APNicant • 1I ,-( ��
y E]N[]Y
❑ NC]
MISC. - REFER TO ORD.
CERTIFICATES OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
section need not be completed if the permit is for one
Y ❑ N ❑
Y C] N F](This
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars IS 100) or less.)
I certify that in the performance of the work for which this per-
mil is issued, I shall not employ any person in any manner so as to
BUILDING
become subject to the Workers' Compensation Laws of California
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex.
emption, you should become subject to the Workers' Compensation
ALTER OR ADD TO MECH. 5.00 ,
APPLIANCE 5.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=11F.M.) 4.00
AIRHANDLING UNIT(OVER 10MC.EM.)6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.CJ.
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATI NG UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lender's Name
Lender's Address
VENTILATION FAN (SINGLE) 4.00
PLUMBING
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
BOILER- COMP (3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said y n consequence of the
PERMIT ISSUANCE 10.00
MECH.CONT. LIC. NO. MECH.
TOTAL
TOTAL
granting of 111 permit
S' are o Applicant ontmctor Dote
OFFICE COPY