12992 (2) APP-LICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
- •y
BUILDING _ APPLICATION & PERMIT
ADDRESS vyy' �1� }���
7 J G. Ts7/a-7ZY Pri BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12992
OWNER'S PLAN CHECK VALIDATION
NAME r��G 973-O,S �V• ELECTRIC PERMIT FEE
t L k/D7 �E/°7P'HONE LE �// T
CONTRACTORS �� UTTS-SWITCHES-RECEP 10.00/1.00 /
LIC.NO. LIGHTING FIXTURES 10.00/1.00 oZ3
CONTRACTOR PPLIANCES-RESIDENTIAL 4.00 ,�
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
OORRCHITFCi PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE'INS. 20.00 �3�LQD
APPLICANT'$ r.�
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE �, 9. �-,_• 20.00f
woo LICENSED CONTRACTORS DECLARATION 3735•{ (a J` Z �/
a v w I hereby affum that 1 am licensed under provisions of Chapter 9 \� ,xv((/������y�'�/�77
h2 [ P11 Qi ISSUAN i AT�EI o
¢H (commencing with Section 7000)of Division 3 of the Business and �` Js BLDG. ELECT. PLG. MECH.
D z Professions Code,and my license is in full force and effect. y LDRtElz o w- License Class Lic.Number
4 w Dara Contractor
Q K E J
¢ IC w ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
A o A
X g A-y I hereby affirm that I am exempt from tire Contractor's License MISC.- REFER TO ORD
u O j Law for the following reason PERMIT ISSUANCE 10.00 e)
(Sec.7031.$,Business and Professions VALUATION S)FT.
L - rnJ
ww Code:Anycity orcounty which requires a permit to construct,alter,
¢ ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC.
o, requires the applicant for such permit to file a signed statement that _9
TOTAL CX
E
w he is licensed pursuant m the provisions of the Contractor's License PERMIT TO
Hzi Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the tTl � .1��y a,_
f 4 c Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE , GJ V
¢ H o the basis for the alleged exemption.Any violation ofSection 7031-5" STORIES TYPE CONSTR.
e- ;m by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(5500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
0 1,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 of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP - 5.00 So.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsare not intended or offered for sale.I f,however,the building GAS-EA.SYSTEM-11N C.4 OUTL ETS 6.00
Or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Orher
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct elle project(Sec.7044,BusinessEl El El 0 El
LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs 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 coniractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORMEA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am a •mpt under See. ,BAP.C.for this
reason WATER HEATER W/VENT 6.00
Owner Dat WATER SYSTEM 5.00
ACG DATE ACC.FILE N0.
WOR KIiR S'COMPENs TION LnRnn N WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of-consent to sell-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.),
Policy No. Company
O 0 Certified copy is hereby furnished.
z .Z Cl Certified copy is filed with the city inspection division. FIRE SPRINK ENERGY T 24
O_ Applicant MISC.- REFER TO ORD. Y ❑ NEl Y ❑ N�
OC y CERTIFICATE:OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.O.
L COMPFiNSAT1ON INSURANCE PLG.CONT LIC.NO. PLG.
OL D (This section need not be completed if the permit is for oneTOTAL v 0 N� V E] N�
�-) Z hundred dollar,IS 100)or less)
0 0 I certify that in the performance of the work for which thisper- D V MECHANICALP FEE SUMMARY
LL I- mit is issued, I shall not employ any person in any manner so as 0 ERMIT FEE
O W become subject to the Workers'Compensation Laws of California. [� >9
D_ Date-Applicant - ALTER OR ADD TOIv1ECH. Ar��f 5.00 OU BUILDING
} y N01'ICI>TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE (')s x
provisions of the Labor Code, you must forthwith comply with 5.00 PLAN CHECK
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNI W6 i0=CF.Mr) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000 C.F M.16.00 SEISMIC FEE ,,//
I horchy uffinn that there is a construction lending agency for, EXHAUST HOOD (WI7JdvDUCT) 5.00 T 7
the purfonnance of the work for which this permit is issued(Sac, MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with it city and county PLUMBING
- ordinances and state laws relating m building construction, and BOILER-
COMP
H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(we) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. �J
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in conwquegce of the PERMIT ISSUANCE . 10.00
gmnti of this pe t. F V_7 MECH.CONT. LIC NO. MECH.
i�t�ss �p-y(.t.a/-yip J/te - TOTAL / l� �
Argnatur�ppbcant/Conlrar�Or- Date �- TOTAL OL
OFFICE COPY