12146 A.PLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER ADILDING APPLICATION & PERMIT
/
AODO a�
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 12146
OWNER'S PLAN CHECK VALIDATION
NANIE I 44 x� OTY. ELECTRIC PERMIT FEE
FLs'Ee✓ PHONE "�V��J O
CONTRACTOR
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC..O. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
p,5P-' L�p.�.1�L PIHOrvE 9�l ��IQJ F7B PANELS 10.00 DATE OF APPLICATION
RCHITEC
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER LIC.No. SIGNS TRANS. 3.00
AEND. PERMIT VALIDATION
ADDRESSDDRESS SPECIAL CIRCUIT
ZIP TEMP.METER OR POLE INS. 2000.
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS A
slL
SERVICE CHANGE '"rs`'- 20.00
Woo LICENSED CONTRACTORS DECLARATION -L s
<u I hereby affirm that I am licensed under provisionsof Chapters) /�P'� ,r" S " .� ISSUANCE DATE
vHi Q h (commencing with Section 7000)of Division 3 of the Business and ss ky . BLDG. ELECT. PLG. MECH.
H O z Professions Code,and my license is in full force and effect. ,810 ❑ ❑ ❑
o,i°'i- License Class Lic.Number ttl
Number-
0 m O Datc Contractor. 0{
F w
`a y BUILDING PERMIT
rt ¢w Q
OWNER-BUILDER DECLARATION INFORMATION
w3 u y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u
Car Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VA WATION $/FT.
- a, Code:Any city or county which requires a permit to construct,alter, �p
. SE aa Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR, LIC.N0. ELEC. �Xd
o LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License
FiQLaw(Chapter 9(commencing with Section 7000)ofDivision 3olthe
E i O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE r
¢ e the basis for the alleged exanption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n;14 by any applicant for a permit subjects the applicant o a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
Of not more than five hundred dollars($500).):
O I,as owner of the property,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 is nm
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 of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 so.Pr.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsule.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 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 im- RES IND CON PB Oona,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ El 13
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 Cmnmetor'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 contractoRs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ lamexempt under See ,B.&P.Gformis WATER HEATER W/VENT 6.00
on
Ow Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereol'(Sec.3800,I.A.C.).
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD. Y[:] N[] Y ❑ N�
Applicant
F- PERMIT ISSUANCE 10.00 FLOGO ZONE A.L.u.c.
LU -
CH RTIFICATEPH ESE IC TINS FROM WORKERS'
UJ > COMPIiNSATION INSURANCE PLG.CONTR. LIC N0. PLG. Y[] N� Y ❑ N
CL O (This section need not be completed if the permit is for one TOTAL
Z hundred dollars(S 100)nr less.)
OTY
U MECHANICAL PERMIT O 1 certify that in the performance of the work for Which this per- . FEE FEE SUMMARY
LL I- mil is issued,I shall not employ any person in any mannerso as to
0L, become subject to the Workers'Compensation Laws of Calitorniu. PFEE
Dale Applicant ALTER OR ADD TO MECH. 5.00
} an NOTICE 'f0 APPLICANT: If,after making this Certificate of F.x-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00
provisions of the Labor Code, you must forthwith comply with suh provisions 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 I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
3097,Civ.C.l.
Lender's Name HEATI NG UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC Q
Lender's Address
1 Certify that I have read HIIs applicallon and slate that the above IVENTILATION 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
ordinances and state Taws relating to building construction. and
hereby authorize representativesoertorns inspection
this city es enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, casts and expenses which CONST.TAX
may in any way accrue against sai City in consequence of the PERMIT ISSUANCE 10.00
gr n[in this permit MECH.CONT. LIC.NO. MECH.
��s TOTAL TOTAL
Signature of Applicant/Conractor Data
OFFICE COPY