12309 (2) 1 ..
.A716PLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 12309
AooREss 0Aa BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER'9 PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
40 ,��� ✓�// PRONE
crDRs
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
S uHr( LIC.No.3 ;1_ LIGHTING FIXTURES 10.00/1.00 I
ADDRESS
oRs APPLIANCES-RESIDENTIAL 4.00
CONTRACTORS
ONDpVVV 111
(� PHONE��,VWa PANELS 10.00 DATE OF APPLICA TIO
ARCHITECT PLAN CHECK FEE
PANELS (OVER 200 AMP) 20.00 PN
�.0.
OR Vv
ENG
}! Y(/
II .No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT V
ADDRESS
A4,P EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS {{
SERVICE CHANGE 20,00 JI I I
woo LICENSED CONTRACTORS DECLARATION MM
a W.� I hereby affirm that I am licensed under provisions of Chapter 9 I R rRM
Naw (commencing with Section 7000)of Division 3 of the Business and BLDG. E MECH.
H D z Professions C.o� y1��my licenso is in lull fur -and f L ff�pTf ❑
z o - License Class_L:_y(_a�Lie.Number ICI. ❑ ❑
o E2 F Date Contractor �,WJ,(j
< Y f BUILDING PERMIT
0 w ¢ OWNER-BUILDER DECLARATION INFORMATION
REFER TO OR
w3 a N 1 hereby affirm tlml 1 am exempt front the Contractor's License MISC.- VALUATIONS $/FT.
H a o a Law for the following reason.(Sec.7031.5,Business unJ Professions PERMIT ISSUANCE 10.00 B�sat
Code:Any city or county which requires a permit to construct,aIle" W.
¢ Q¢ 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
- D w requires the applicant for such permit to file a signed stetemcnt that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License give-
HiQBusiness
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe CO (J'l
and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ Hp the basis for the alleged exemption.Any violation ofSection 7031.$ STORIES TYPE CONSTR.
or S. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500t):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5,00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 so.Fr.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such in"'mIc-
'� meats are not intended or offered for sale.If,however.the building GAS-EA.SVSTEM-11NC.40UTLET$ 6.00
ar 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 , REB IND CON PB Olhmr
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,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 Contractors 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 commetorts)licensed pursuant In
the Contractor's License Law. I SEWER-SANITARY-STORM EA.200ft/10.00 TEACTNO. PARCEL NO.
❑ tum exempt older Sec. ,B.&P.C.lin this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACF FILE NO.
WORM'RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent o sel Closure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensa ion Insurance,or ceLrtified
copy thereof(Sec.3800,Lab.CJ, -lam r A
Policy N`I�a/.7[CompanY /
Q ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T-24
Z Z � Certified copy is 01(d with the city inspection division. MISC.- REFER TO ORD. v ❑ N❑ Y ❑ N❑
F O A(rplicant ��laIs P L,
fry CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A,L.U.C.
11J > COMPI!NSATION INSURANCE PLG.CONTE. LIC.NO. PLG. Y[:] N❑ Y[:] N❑
EL ❑ 1'I his section need not be completed if the permit is for one TOTAL
D Z hundred dollars IS 100)m less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL k- mil is issued,I shall not um ploy any person in any Insurer sn as to
Ow becomesuhjecttothe Worker Compensatiol Laws of California BUILDING 1 ,71. ",
/ , QO
a Date-Applicant ALTER OR ADD TO MECH. 5.00 t
} m NOTICE 'I'O APPLICANT: If,utter making this Certificate of E--
Z emplion,you should become subject In the Workers'Compensation APPLIANCE 5. 0 PLAN CHECK /
provisions of the Labor Code, you must forthwith comply with FEE 76-
U such provisions or this permit slmll be deemed revoked, AIR HANDLING UNIT(TO 10=C.F.M.) 4
CONSTRUCTION LENDING AGF.NCI' AIR HANDLING UNIT(OVER t0,000C.F.M.16. 0 SEISMIC FEE , D
1 hereby affirm that there is a construction lending agency tar 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 MICRO FIL
3097,Civ.CJ.
Lender's Name
Lenders Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 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 coup Iy PLUMBING
t ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP love,100,000 BTU)SEE FEE SCH. MECHANICAL
s� x above-mentioned property for inspection purposes. /
;: (WC) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
...r. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gmntingofthis permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL ,
Signature of Applicant/Contractor Date
OFFICE COPY