12787 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
>! a IIiFess 11000 N• WOLFS fQD, APPLICATION & PERMIT
_ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 12787
OWNER'S PLAN CHECK VALIDATION
NAME 7?S"Sl/1 CITY. ELECTRIC PERMIT FEE
B�LE7T k PHONE X 5109
CONTRACTOR'S OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
\ yEaI`M _ f/ C C.NU 5 Q,'S7 LIGHTING FIXTURES 10.00/1.00
X ADDREScroR's PPLIANCES-RESIDENTIAL 4.00
S C) PHONE 1 8-974q PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.L.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. 5.00
PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
EMP.METER OR POLE INS. 20.00
zlv / n
APPLICANTs MOTORS SEE FEE SCH.
ADDRESS
S ill
SERVICE CHANGE 20.00 !
woo LICENSED CONTRACTORS DECLARATION
a.u I hereby affirm that I am licensed under provisions of Chapter 9 IS UANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r0 i Professions Coyle d license is in full for eae ❑ ❑ ❑ T Q
i D,n - License Class`- Lic.Number-��,r� e+� A
9 m r w Date�"Z q _Commet.,3HAT.91_N
a y BUILDING PERMIT
tt ¢ w u OWNER-BUILDER DECLARATION INFORMATION
K LL I hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD
_ LL0< Law for the following reason.(Sec.703 L5,Businessand Professions PERMIT ISSUANCE 10.00 vALunnoN $/FT.
Code:Any city or county which requiresa permit toconstrUCL alter,
2 5 Q O improve,demolish,Or repair any structure,prior m its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- O LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT Tp
M
$w he is licensed pursuant to the provisions of the Contractor's License
wz0 Law(Chapter9(commencingwith Section 7000)ofDivision3ofthe
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
3 t DSTORIES TYPE CONSTR.
¢ H $ the basis for the alleged exemption.Any violation of Section 7031.5
a ; _ by any applicant fora permit subjects the applicanttOreivil Penalty gLTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).},
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole LORIPensallun,will do the work,and the structure is not
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.FT.FLOOR AREA TOTAL ACREAGE
1 himself or through his own employees,provided that such improve-
mreGAS-EA.SVSTEM-i INC.40UTLETS 6.00
enus are not intended or offend for sale.IL however.the building
Or improvement is sold within one year of completion.Dm owner- GAS-EASYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have tile .e burden of proving that he did not build or im- RES IND CON PS Other
prove for purpose of sole.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,[rosiness LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCELNO.
and Professions Code,Thu Contractor's License Low docs not apply
to an owner of p,,,Perry whoro
builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmctons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ lam exempt under See. ,E.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a Certificate ofconsent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec 380 ,Lh.C.
Policy NON�' I onipany�/nME7CAN0 /A/5
C) ❑ Certified co yis hereby furnished. FIRE SPRINK ENERGY T-24
Z Z/1ertificd I+ 1s fi with the city inspection division. MISC.- REFER TO ORD. y ❑ N� Y ❑ N[]
F O pplivant
c W CERTIFICA'I .OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y N v N
CL a (This section need not be completed if 0te Permit is for o� TOTAL
� Z hundred dollars IS 100)or less.) m
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICA FEE FEE SUMMARY
l.L P mit is issued.I shall not employ any person in any manner so as to t
U aw I
Wbecome subject to the Workers'Compensation Lows of California BUILDING
Date Applicant ALTER OR ADD TO MECH. .00
} N NOTICE TO APPLICANT'. If,after making this Certificate of Ex
f" ? emptlon,you should become subject to the Workers'Compensation qpP LIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT O 10,000 C.F.M.1 . 00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(O .00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 '�-e-
the performance 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(OV E R 100,000 B.T.U.).9.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
Information n correct I agree to comply with c city and county BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00 PLUMBING
ordinances and stale laws coloring to building construction, and
hereby authorize represenlmives of this city m enter upon rho BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
I above-mentioned property for inspection purposes. 1
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMITISSUANCE 10.00 Q CONST.TAX
may in any way accrue against said City in consequence of the �L
granting LY lh nnil. MECH.CONT, a5 ED1.57 MECH
TOTAL ✓t.
�� . TOTAL
Signal of Applicmtl/Contractor Date TNERMR�-M ESN [GAC..
OFFICE COPY