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2898 APPLICANT TO FILL IN INFORMATION WITHIN'RED LINES - LISE'BA'LI-_ POINT PEN.ONL1 BUILDINGPROJECT IDENTIFICATION % EH U PER BUILDINGAPPLICATION & PERMIT O Q,Q - - O J U BUILDING-ELECTRICAL-PLUMBING'-MECHANICAL PLAN CHECK VALIDATION TY. ,"ELECTRIC;PE'RMIT ._ FEE .. ./1 CONTRACTORS i. NAME � OUTLETS'-SWITCHES-RECEP -5.00/1.00 AGE uc N LIGHTING FIXTURES 5.00/1.00 °O APPLIANCES-RESIDENTIAL i 4.00 Ao PANELS 5.00 DATE OF APPLICATION *' R i , - •• PLAN CHECK FEE J P.C.NO. OR ��� . =.6.00 - ENSiAN JOSE, C 4 951.10 SIGNS ic'iao. SIGNS TRANS. '- 3.00 _ - ADDRESS - ERMITy.IIhIRGT PN ADDRESS SPECIAL CIRCUIT 5.00 1 AfAI . ..nP. TEMP.METER OR POLE INS. - 15.00 APPLICANT s ADDREDFESS S MOTORS 'SEE FEE SCH'. ;� ` ,F EB 18 1983 • SERVICE CHANGE 10:00 - w o o LICENSED CONTRACTORS DECLARATION City Of Cupertino a u p' I hereby affirm that I ate licensed under provisions of Chapter 9 ISSUANCE DATE" ac (commencing with Section 7000)of Division 3 of the Business and i Professions C e� y license is in fulL,ftyPg�Ir�l BLDG. ELECT. PLG. MECH. ` z0.G License Class Lic.Namh -[S1 -OWNF -� '0 9 m Datc Contractor Gyhr� Ci S, BUILDING PERMIT i O R=N UILDER DECLARATION. - ( " INFORMATION a` w ;. ti v I hercby•aflirm that I.am exempt from the Contractor's License, MISC.'- - REFER TO ORD vALUAn ON $/FT. Y ac o g' Law for the following reason.(Sec.7031.5,Businessland Professions PERMIT ISSUANCE - 6.00 Code:Any city or County which requires a permit toconstant,slier, ' Q �'Q 0 Improve,demolish,or repair any structure,prior t°Its issuance,also ELEC.CONTR. LIG NO, ELEG - - 0 , requires the applicant for such permit to file a signed statement that - - TOTAL X m m_ he is licensed pursuant to the provisions of the Contractor's License _ PERMIT TO E z rt Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE, X r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE cbNSTR. by any applicant for a permit subjects the applicant too civil penalty' ALTER-DRAIN (EA) 4.00 ' of not more than five hundred dollars(S500)J - - . : - ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE.. 2.00 OCC.GROUP � their sole compensation,will do the work,and the,structure is not REs.UNITS intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,POND. 4.00 - Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who docs such workFIXTURES-PER TRAP 4.00 soFr PLooRAREA TOTAL ACREAGE himselLor through his own employes provided that such improve - . �- mems are not intended or-offeredt r sale.If,however,the buildi g GAS-EA.SYSTEM=I INC:4'OUTLETS 4.00 or improvement is sold within onc,year of cornpl tion,the owner- , GAS-EA.SYSTEM-OVER 4 (EA.I 1.00 RUILDING.uSE• budder will have tire burden of proving that he did not build,or am- prove for purpose ofsale.). - RES IND CON PR Other ❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTEIN,TE R. _ 20.00 El1:1 .,❑ ❑ ❑ licensed contractor, Io construct the project(Sec. 7044,Business LAWN'SPRIN KLERS-1 INC 5 V.B. 5.00 AssESsoas PAR CEL NO.,. and Professions Code:The Contractor's License 1:5w does not apply - to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00 - - contracts for such projects with a conlractons)licensed pursuant to the C'ontractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO. ❑ lam exempt under Sec. ,B.&P.C.for thin WATER HEATER-W/VENT -4.00 reason Date - "Owner WATER SYSTEM - 4.00 ACO.DATE ACC.FILE No. WORKIiRS'COMPE NSAT'ION DECLARATION WATER TREATING EQUIP. 4.00 I hereby affirm that I have a certificate ofconsem to self-insure, or a certificate of Workers'Compensation Insurance,or a certified 'ZONING ENG.SITE NO. `{t�hereof a Lab.C.l (�/� �y Perry S.1L110 f _ _ 0_ 'Letlt eh erebyl'uridled. FIRE SPRINK ENERGY TH4 Z Cer" why rs f vi� 1 city inspection divisi I. P,O Applicam MISC:-. :REFER TO ORD. y ❑ N Q Y'❑ No PERMIT ISSUANCE ' 6.00 FLOOD ZONE A.L.0 C. � w CERTIFICATE E SATIO IN � N WORKERS' C''G W COMPENSATION INSURANCE. - PLG.CONTR. - u0.N0. PLG. 1 O (This section need not be'completed if the permit is for one r - TOTAL1©1M Y❑ -:N❑. ,Y ❑ N❑ Z: hundred dollars IS 100)or IessJ - - U O' ('certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE ' FEE SUMMARY LL 1- - mil is issued, I shall not employ any person in any manner so as to - -U become subject to the Workers'Compensation Laws of California. y. ,Date ApplicantALTER OR ADD TO MECH. 4.00 BUILDING -. } to NOTICE TO APPLICANT. 1(,after making this Certificate of Ex- - - FZ 'eruption,you should become subject to the WorkeWCompensation APPLIANCE. .4.00 PLAN CHECK provisions of the Labor Code, YOU most forthwith Comply with FEE - U' such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.I .3.00 - CONSTRUCTION LENDING AGENCY ,-, AIR HANDLING UNIT(OVER:IO,000C.F.M.) 5.00 'SEISMIC FEE - I hereby affirm that there is a Construction'lending agency for EXHAUST HOOD WITH DUCT) 2.00 ' the performance of the work for which this permit is issued(Sec, MICROFILM 9097,Cie C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 - Lender's Name Lender's Address - HEATING UNIT(OV ER 100,000'B.T.U.)7.50 ELECTRIC 'I certify that l have read Ilii;application and state that thea hove VENTILATION FAN (SINGLE) 3.00 .� information is correct. I agree to.comply with all city-and county PLUMBING Ordinances and-state laws relating to building•pmstrtmtioii, and ' BOILER-COMP(3 H.R cr100,000B.T.U.) 4.00 •hereby authorise reptescnmtives of this city to enter upon the BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL ahove-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 may,in any way accrue against;aid City in consequence of the PERMIT ISSUANCE 3.00 ' •. ran tin of is permit. . MECH.CONT. LIC.NO. ' MECH. - )JSBOTAL' TOTAL eture of Applicant/Contractor [)are NI to. x OFFICE COPY