12983 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY02��
.•'BU I LDI NG P ROJECT I DENTI FIC TION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 12983
ADDRESS BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
o3S d<!Qf
OWNER'S PLAN CHECK VALIDATION
• NAME • OTY. ELECTRIC PERMIT FEE
� PHONE
CONTRACTOR'S ��d�, UTLETS-SWITCHES-RECEP 10.00/1.00
a
NAME J
GlF,vTer�l
LOC.N ' LIGHTING FIXTURES 10.00/1.00
ADDREScioRs APPLIANCES-RESIDENTIAL 4.00
CONTRAS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCNrtECiPANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. ISIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT•$ MOTORS SEE FEE SCH.
ADDRESS
5e' �! S �, S ,j// SERVICE CHANGE 20.00 ��/,�/y
w O o LICENSED CON'T'RACTORS DEC ATION _ S�/ //0
a u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUA CE BATE
as<A, (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H y z Professions Cod Fand license is in full force and of g ❑ ❑ ❑
z O w- License Class Lic.Number
0 w Date�-��-_Contractor��d,' -
< y I J ,��.T,ce "67 BUILDING BUILDING PERMIT
¢ ¢w OWNER-BUILDER DECLARA ON INFORMATION
D MISC.- REFER TO ORD
E
3 LL as- 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
R w 0 J Law for the following mason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or camly which requires a permit to construct,offer,
a ¢¢2O improve,demolish,or repair any structure,prior W its issuance,also ELEC.CONTR. LIC.NO. ELEC.
u - 0, requires the applicant for such permit In fife a signed statement flint TOTAL PERMIT TO
whe is licensed pursuant to the provisions of the Contractor's License g
i Law(Chapter 9(commencingwioT Section 7000)of-Division 3 ofthe LB�
s i o Business and Pr fessions Code)or that he isexempt therefrom and OTY. PLUMBING PERMIT FEE
¢ I- file basis for the eged exemption.Any violation nf8ecfion 7031.$ STORIES TYPE CONSTR.
A. by any applicant a permit subjects the a pp' a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than fl hundred dollars(S50
❑ I,as owner of m property,or t employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensatin will do th .,it,and the structure is not
intended or of(ercd far. Ie IS . 044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code:The Contractor's Li Law does not apply to nn owner of
property who builds or r es thereon,and who does such work FIXTURES-PER TRAP 5.00 O. Sp.FT.FLOOR AREA TOTAL ACREAGE
himself or through I' wn em gees,provided that such improse-
ments are not in or often orsale.lf,however,the building Ak GAS-EA.SV$TEM-i INC.4OUTLETS 6.00
or improvement is sold within o,I ear of completion, the owner. GAS EASYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or I.... - .. BUILDING USE
prove for purpose of safe.). RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ 0 0 ❑
licensed contractors m Construct the project(See.7044,Business LAWN SPR INKL C 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to on owner of property who builds or improves Thereon,and who LAWN SPRINKLER$-OV EA.) 1.00
contracts for such projects with n contraclor(s)licensed pur,mm to SEWER-SA V- .200ft/10.00
TRACT NO, PARCEL NO.
the Contractor's License Law.
❑ 1 nm exempt under See.-,li.&P.C,for ads WATER HEATER W/VENT 6.00
reason
OwnerUme WATER SYS 5.00 SOg ACC.DATE ACC.FILENO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that 1 have a certificate of consent to self-insure. ZONING
Or n certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Se..3800,Lab.CJ.
Policy No. - any
Q ❑ Cer il'ied COPY Ts hereb T'urnislTed, FIRE SPRINK ENERGY T 24
Z Zedified cIs fl with the.Cify inspection division.
O Applicunlop�� d E./�/i1 MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N[]
� y
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.0Of FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC /;7/531 PLG.
O (This Section need not he completed if The permit is for one 6�/lii" J! TOTAL Y❑ IN Y D N[]
Z hundred dollars IS 100)or less.)
U O 1 certify1hn the parfuramBee of the wor for which Ibis per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
.�
H mit is issued, I so the toy any pe e•f T any manner so to
0 U become subject m the Workers s:rtion Laws of California.i
CL Datc Applin ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICE TO APPLI : If,after making this Certificate of Ex-
F... Z emption,you sl become subject To om Workers'Compensation APPLIANCE 5.00 PLAN CHECK
prov¢Tons he Labor Code, you must forthwith comply with FEE
U such prq 'tens or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performanc of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,CIv.C.).
Lende'r's Name HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read th' plication a ,ate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 e to comply with all city and county PLUMBING
ordinances and stat s relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorit epresentatives of this city to Doter upon the BOILER-COMP (Over 100,000BTUI SEE FEE SCH. MECHANICAL
above-mentio d properly for inspection purposes.
(We) agree to save, indemnify and keep hornless the City of MISC.- REFER TO ORD.
Cupertino against liat4litics,judgments, costs and expenses which CONST.TAX
may in any ay Il"e against said judgments,
in consequence of file PERMIT ISSUANCE 10,00
granlingoft perni MECH.CONT. LIC.NO. MECH.
TOTAL
TOTAL
q9triature of Applicant/Contractor Date Uafe 11
OFFICE COPY