12996 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
'y BUILDING -r- APPLICATION & PERMIT 12996
ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
�// OWN R'S PLAN CHECK VALIDATION
r1 NAM OTY. ELECTRIC PERMIT FEE
PHONE
NgMTGncroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
uc.No.3 ,3�1 LIGHTING FIXTURES 10.00/1.00
DDREAc70R's
AAPPLIANCES-RESIDENTIAL 4.00
CNTR1
[L) PHONE. •It 13 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
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
APPLICANT'S ���"/,.f✓�/r+'
ADDRESS 1 k4erscskoe cd • MOTORS SEE FEE SCH.
c W SERVICE CHANGE 20.00 'J
w00 LICENSED CONTRACTORS DECLARATIO
a U 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 BLDG, ELECT. PLG. MECH.
a e nd m license is in full fur 1 1. ❑ ❑ ❑
F o i Professions Code,' �E
2 o or License o" 0 "� Lic.Number(
2 F Date�l$T Contractor
y a BUILDING PERMIT
rZ is w u OWNER-BUILDER DECLARATION
o W. MISC.- REFER TO ORD INFORMATION
F
3 y 1 hereby affirm that I am exempt from the Contractor's License
Fuca Law for the following reason. 7031.5,Business and Professions PERMIT ISSUANCE - 10.00 VALUATION $/FT.
NW Code:Anycily orcounly which requires a permit to construct,alter,
2 < improve.demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
- DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
u whe is licensed pursuant to the provisions of the Contractor's License
i
FzLaw with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
at F. o the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR.
i3 $ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -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
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5,00
Code:The Contractor's License Law does not apply to an owner Ot
M property who builds or improves thereon,end who does such work FIXTURES-PER TRAP 5,00 50FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended orOffered for Sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or"Provement is sold within one year of completion,the Owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have Ilse burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omar
❑ 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 ASSESSORS PARCEL NO.
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 contractorts)licensed pursuant to
IIIc Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lamoxemptundcr Sec. ,B.&P.C.fortliis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ALL.DATE ACO.FILE N0.
WORKERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a Certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereol'(Sec.3800,Lxb.0.).
Policy Nn. Company
0 ❑ 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 V E] NC] V ❑ NE]
LU CERTIFICATE OF EXEMPTION FROM WORKERS'
1'" tn PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.c.
W �_ COMPENSATION INSURANCEPLG.CONTR. LIC.No. PLG,
CL Cl er
(This section need not he completed if the pmil is for one TOTAL Y❑ N❑ Y [:] N❑
0 Z hundred dollars IS 100)or less.)
V O I certify that in the performance of the work for which this Por- T MECHAI 1PMIT FEE FEE SUMMARY
LL Emit is issued,I shall not employ any Per n i I any manner so as to
U beco_m• b�'e}• he Workers' open La s o(CalRornia.
(L Dalev.-'="-'-APPllcant a ALTER OR ADD TO MECH.,'� 5,00 BUILDING
} In NOTICE TO APPLICANT: iter making this CL lificate of Ex-
L- ? emption,you should beco object to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
,provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UN TO 10 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT( ,000C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.0.). - t HEATING UNIT(TO 100,000 B.T.U.) B4O0 3.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify ,,or I have read Ihis application and state that the ubove r3 VENTILATION FAN (SINGLET 4.00
information is correct. I agree to Comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.1 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP to.,100,000 BTU)SEE FEESCH. MECHANICAL
< above mentioned property for inspection purposes. Q
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 , t(',� CONST.TAX
may in any way ccme against said City in consequence of the
grant' of this pe it. MECH.CONT. LIC.NO. MEETAHL ' 0
\ TOTAL
pplicanljContr aor • Date e1 83
` OFFICE COPY