12580 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
Bu1LDINc APPLICATION & PERMIT 12580
ADDRESS BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
1o/
OWNER'$ PLAN CHECK VALIDATION
NAME - QTY. ELECTRIC PERMIT FEE
e PRONE
CONTRACTORSUTLETS-SWITCHES
-RECEP 10.00/1.00
NAME
hW4P Q PG uc.rvo. / LIGHTING FIXTURES 10.00/1.00
forvTRAGTo 's APPLIANCES-RESIDENTIAL 4.00
ADDPE55 p
+ -P PHON 3J- + PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OP
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
TIP rrEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. a1
ADDRESS
�U �
I- l/
w O o LICENSED CON'T'RACTORS DECLARATION SERVICE CHANGE
a u U, I hereby affirm that I am licensed under provisions of Chapter 9 _ e' ISSUANCE DATE
P,<H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w Professions Code, nd my lir�nse is in full fort an of e((t� 7
Z
Licen Cla _ V Lia Number y I O �p In ❑ ❑ ❑
Date Contractor � / BUILDING PERMIT
Ic w OWNER-BUILDER DECLARATION INFORMATION
o A MISC.- ER TO ORD
E:
; w w I hereby affirm that I am exempt from the Contractor's License VALUATION
FLL0J Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Anycity orcounty which requires a permit to construct.alter. ELEC.CONTR. LIF NO.
aca ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.
O 0 requires the applicant for such permit to file a signed statement that TOTAL �� PERMITTO
n w m tie is licensed pursuant to tie provisions of the Contractor's License
i Law(Chapter 9(commencingwithSection 7000)ofDivision3ofthe �LEG7
< Business and Professions Code)or that lie is exempt therefrom and OTY. PLUMBING PERMIT FEE a
the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
T ; - by any applicant for a permit subjects the applicant tea civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as IBACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do tie 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 F IXTUR ES-PER TRAP 6.00 SQ FT.FLOOR AREA TOTAL ACREAGE-
himself re through his own emred fors,provided that such improve-
menlsarenot imhhisended oroffereoy"s,prove. ided
that such
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 BUILDING USE
builder will have the burden of proving that he did not build or am.. RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ El El El 11❑ I,as owner of the property,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 does 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 conimetoro)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-.B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACG DATE ACC.FILE NO.
WORKF.RS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to scl l'-Insure, ZONING ENG.SITE N0.
r a certiELnte of Workers'Compensation Insurance,or u ecrtificJ
Copy fl eZ�f�,Sec. QQ Lab.C.1/� 7-T�
Policy Ntta[L.DI/�d'°mPanY_S-4.f -/ _
O 0 Certified Copy is hereby�fuWr�nipshed. FIRE SPRINK ENERGY T 24
Z Z 0 Certifie opy i��1vi11X city inspection division. MISC- REFER TO ORD. Y❑ N❑ Y ❑ N❑
Applicant- C4I'�
N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
W >_ COMP[]NSATION INSURANCE PLG.CONTR. LIC.NO. 'LG
.AL Y
LuQ TOT ❑ N❑ Y N❑
(This section need not be completed if the permit is for one
Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
❑, H mit is issued.I shall not employ any person in any manner so as to
O W become subject to the Workers''Compensation Laws of California. BUILDING
Dec Applicant ALTER OR ADD TO MECH. 5.00
>_ y NOTICE TO APPLICANT': it,alter..king this Certificate of Ex-
(_ ? cmptiom,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 1000C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 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,Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 /
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC `7q "_
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 BOILER-COMM H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEESCH. 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 CONST.TAX
ue
may in any way accragainst Said City in consequence of the PERMIT ISSUANCE 10.00
granting of this permit n MECH.CONT. LIC.NO. MECH.
_ e * Aa,,-'- 14-6-07 TOTAL TOTAL
Sgnatur of Applicant/Contractor Date /
FFICE COPY /