12716 APPLICANT TO FILL IN INFO TION WITHIN RED LINES - USE Bnl-L POINT PEN ONLY
BUILDING PROJECT 1 DENTI FICA PERMIT NUMBER
BUILDING APPLICATION & PE 1
PooREss/ D. BUILDING -ELECTRICAL-PLUMBING-MECHANICAL127
WNER'a PLAN CHECK VALIDATION
NAME _ QTY. ELECTRIC PERMIT FEE
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
C.NO. LIGHTING FIXTURES 10.00/1.00
CO TRACT s APPLIANCES-RESIDENTIAL 4.00
13
ESS
y!VPHON PANELS 10.00 DATE OF APPLICATION
AR RITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
- OR '
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. PERMIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS -
SERVICE CHANGE 20.00
00 LICENSED CONTRACTORS DECLARATION
< u I hereby affirm thio 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
h<w., (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r D z Professions Cod mlzt license is in full fort I W f '� ❑ ❑
Z O m,�-,C License Clas Lie.Nutormber
z �J Date Contrac
m s BUILDING PERMIT
a:w u OWNER-BUILDER DECLARATION INFORMATION
0 MISC.- REFER TO ORD
X
3 w I hereby affirm IhatJ am exempt from the Contractor's License VALUATION
r u o J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 $/FT.
Code:Any city or county which requires a permit to construct,alter,
2R¢ E improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
D, requires the applicant for such permit In file Sabred Statement that TOTAL PERMIT Tp
aL K $ he is licensed pursuant to the provisions of the Contractor's License MPERM
Z a Law(Chaprer 9(commencingwith Section 7000)MDivision 3 ofthe
Z 4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT - FEE
r S the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR,
by any applicant for a permit subjects the applicant loacivil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UMTS
their sole compensation,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 ripply to an owner of
Property who builds or improves thereon,and who does such work FIXTURES,PER TRAP 5.00 sa FT.FLOOR AREA TOTAL ACREAGE
himself through his own employees,provided than such improve-
ments arere not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 I NC.4 OUTLETS 6.00
Or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im. RES IND CON PB Omer
prove forpurposeof theJ. INDUSTRIAL WASTE INTER. 30.00 ❑ 0 Q Q Q
❑ d as owner of the property,he 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 does not apply
to anowner of property who builds tr improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a conlmeoor(s)licensed pursuant to SEWER-SANITARY-STORM EA,200ft/10.00
the Contractor's License Low. TRACT N0. PARCEL N0.
❑ 1a exempt under Seas ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale 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 of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.CA
26 Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
z ❑ Certified copy is fled with the city inspection division..
Applicant MISC.- REFER TO ORD. Y ❑ N❑ Yo No
CC T CERTI FICATE 017 EXEM PTION 17HOM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
D. O (This Section need not be completed if the permit is for one TOTAL Y O N� Y[] N�
0 Z - hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work I'or which this per- OTY. MECHANICAL P MI� FEE FEE SUMMARY
LL F- mit is issued, I shall not employ any person in any manner so as to !f►��
U becom•sulyyct he Workers'�p�p�r,, Laws of California.
U y Dataa, _/(e.Ld.,L Applicant�tS,I � ALTER OR ADD TO MECH. 0 BUILDING
} h NO CE TO APPLICANT: If,after making this Certificate of Ex-
♦- Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code• you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TA
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER MR.1-6.00 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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name - HEATING UNIT 100,000 B.T.U.)9.50 S
Lender's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
informationiscorrect. I agree to comply with all City and county PLUMBING
ordinances and state laws relating to building construction. and BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00 rn
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTUI 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, Costs and expenses which' PERMIT ISSUANCE 10.00 Q CONST.TAX
may in any way accrue against Said City in consequence of the
grantln oflhisper if - MECH.CONT. UC.NO. MECH.
�� �6_� TOTAL �C� IZJ TOTAL
ature Applicant/Conlmctor Date '��
OFFICE COPY