11612 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDR`ESSS/y/ � �� BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 11612
OWNER'S PLAN CHECK VALIDATION
rvn��M/yE/I ,�...�))_� L��✓ OTY. ELECTRIC PERMIT FEE
/"• (/`4 �G� PHONE
NAMENACTORS x OUTLETS-SWITCHES-RECEP 10.00/1.00
/A,7e. LIC.NO.,? 023 LIGHTINGFIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESSOy
�[7%Z�sX^ActCe PHONE PANELS 10.06 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,06 PLAN CHECK FEE P.C.NO.
OR
ENGINEER LIC.NO SIGNS TRANS. 3.00
ARCH,OR ENG. - SPECIAL CIRCUIT SQQ PERMIT VALI DATION
ADDRESS .
ZIP EMP.METER OR POLE INS. - 20.00
ADDRESS - MOTORS SEE FEE SCH.
ADDRESS -
- SERVICE CHANGE 20.00 -
°w o o LICENSED CONTRACTORS DECLARATION 8'` —1
u u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
'LL's Professions Cog&and license is in full fore and effetL ❑ 1:1 ❑
Z o a'Ai— License a Lic.Number O
lite ' ContractD
IF= a OWNER-BUILDER DECLARATIO 16
BUILDING PERMIT
> w U MISC.— REFER TO ORD INFORMATION
w ; LL N 1 hereby affirm that I am exempt from the Contractor's License
LLD ¢ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
w N Code',Any city or county which requires a permit to construct.alter,
0 improve,demolish,or repair any structure,prior toits issuance,also ELEC.CONTR. 1 LIC.NO. ELEC.
u — DLL requires the applicant for such permit to file a signed statement That TOTAL PERMIT TO
E he is licensed pursuant to the provisions of the Contractor's License Yx
r z aLaw(Chapter 9(commencing with Section 70000of Division 3 ofthe 10`off
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
M r the basis(or the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i;� 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(E500).): -
❑ 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 not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.0
Code:The Contractor's License Law does not apply to an owner of
i property who builds ar improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SD.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improveAa W
-
ments areno(intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner GAS,EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE - 30.00 RES IND CON PB Other
Cl I,as owner of the properly,am exclusively conlmcting with ❑ ❑ ❑ ❑ Cl
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLE 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Commew's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVEEA.R 5(E 1.00
contracts for such projects with a contractor(s)licensed pursuant to .)
SEWER•$ANIT TO -200ft/10.00 TRACT NO. PARCEL NO.V
the Contractor's License Law.
❑ l am exempt under Sec..,B&P C.for this WATER HEATER W/V 6.00
reason
Owner Dale WATER SYSTE 5,00 ��'
ACO.DATE ACG FILE NO.
WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm Ihat'l have u certificate of consent to self-insure, ZONING
r a certificate of Workers'Compensation Insurance,ora certified ENG.SITE NO,
opy thereof(Sec.3600,Lab.CJ,
Policy No. Company
❑ Certified coy
is hereby furnished. FIRE SPRINK ENERGY T24
Z Z •
cant❑ Certif y I By Insp�clion division. MISC.- REFER TO OR
O Appli ❑ ❑ ❑ ❑
a Y N Y N
H CERTIFICAT F EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 C� FLOOD ZONE A.L.U.C.
LU �_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. ❑ ❑ ❑ ❑
C a (This section need not he completed if the permit is for one TOTAL Y N Y N
2 hundred dollars(E100)or loss.) -
V O I certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL mit is issued,1 shall not employ any person in any manner so as to
CI become subject to the Workers'Compensation Laws of California.
i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE.TO APPLICANT: If,after making this Certificate of Ex-
2 erhmion,you should become subject 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 UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DWIC.F.M.) 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,CivC.). HEATING UNIT(TO 100,000 B.T.U.) 8,00
Lender's NIS
Leader'sUNIT(OV ER 100,000 B.T.U.)Lender's Address ELECTRIC
• 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 state laws relating to building construction, and BOILER•OOMP(3 HA Or 100,000 B.T.U.) 6.00 A
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
-
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in a y way accrue agai st said City in consequence of the PERMIT ISSUANCE 10.00
gra This pe MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature of App I/Contraclor Date
OFFICECOPY
i