12315 APPLICANT TO FILL IN INFO MATION WITHIN RED LINES - USE 9ALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FIC N PERMIT NUMBER
7 nooeesi APPLICATION & P IT 12315
O rn In 4,1I BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OrvNER'S PLAN CHECK VALIDATION
• / NAME QTY. ELECTRIC PERMIT FEE
l PHONE
CONTRACTOR'S UTLETS-SWITCHES-RECEP 10.0011.00
f NAM
'O UC.NG.qzw LIGHTING FIXTURES 10.00/1.00
r,ONTRACTOR's PPLIANCES-RESIDENTIAL 4.00
ADDRESS
1 :5Zh M/ t PHONE Z PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMPI 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS ZIP EMP.METER OR POLE INS. 20.00 n
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 PAW-
�/�
w O o LICENSED CONTRACTORS DECLARATION 9 1
< v u I hereby affirm that I am licensed under provisions of Chapter 9 y • E DATE
Z (commencing with Section 7000)of Division 3 of the Busines and
j'� ProfeSsioni Cod d my license is in full fere ffeCL BLDG. ELECT. PLG. MECH.
Z i�, _ y, Littnu Class_ _ Lin.Numhe� ❑ ❑
H Datc Contractor �I rn urn
F x g _ BUILDING PERMIT
¢ ¢ w Cai OWNER-BUILDER DECLARATION INFORMATION
w 3 LL _ I hereb affirm that I am exempt from the Contractor's Liveme MISC.- REFER TO ORD
Y P VALUATION S/FT,
Fu 04 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any City or county which requires a permit to construct,alter,
rt2Q improve,demolish,or repair any structure,Prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
so
D 1, requires the applicant for such permit to file a signed statement that TOTAL PERMITTO
whe is licensed Pursuant to the provident of the Contractor i Licerue
F z a
Law(Chapter 9(commencing with Section 7000)of Division 3 of the v of �N7
f It
E D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
the basis for the alleged exempli0n.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant fora permit subjects the applicant loo civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not mom than five hi ndmd della.(5500).):
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is n01 OCC.GROUP RES.UNITS
intended or offered for sale (Sec, 7044, Business and Professions 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 docs such work F IXTUR ES-PER TRAP 5.00 S6 FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1 6.00
meets arc not intended or offered for sak.If,however,the building
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 int- RES IND CON PB Other
prove for purlxm of salCJ. INDUSTRIAL WASTE INTER. 30.00
Cl 1,as owner of the pm Perty,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 dun not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projects with a contractor(s)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.fur Ibis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM. 5.00 ACC.DATE ACG.FILE NO.
WORKCRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of Consent to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,Or a certified _ -
copy thereof(See.3800,Lab.C.).
Policy No. Company E P1I
❑ Certified copy isherehy fur nis •d. FIRE SPRINK ENERGY T 2a
Z Z ❑ Certifi opY rs fil•I Tit the city ins ction di,ision. MISC.- REFER TO ORD. y❑ N❑ Y ❑ IN E]
O APPlicanl -
~ rn PERMIT ISSUANCE- 10.00 FLOOD ZONE A.L.u.c.
cc CERTII°ICATE F MIC
1 1PTI p tlkNt!RS'
LU _ COMPEN ION I ANCI- PLG.CONTR. LIC.NO. PLG.
1 O (This section need not be completed if the permit is forgone TOTAL YE] N❑ Y ❑ N❑
Z hundred delta.($100)or less.)
U O 1 certify that in the Performance of the work for which this per. CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL U mil is issued.I shall nm employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California..
n. Datc APPhcant ALTER OR ADD TO MECH. 5.00 BUILDING
>_
W NOTICE TO APPLICANT: If,after taking this Certificate of Ex-
2 emption,you should become subject to the Workers'Compensation APPLIANCE 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(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE AYO
1 hereby affirm that there u 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.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UN IT(OVER 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 is Correct.I agree to Comply with all city and county PLUMBING
ordinances and stale laws relating to building Construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
L hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes
(We) agree to save, indemnify andkeep harmlei the City of MISC.- REFER TO ORD.
Cupertino against.liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in y way accrue ainst aid Cit m consequence of the
gran ofthisPe y MECH.CONT. LIC.NO, MECH.
XPIMA, Lt TOTAL TOTAL
eure6 Ap a 'jol'irctorr Date
OFFICE COPY