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4037R ft O Z_z 0 = T W _ ao D UO EL U Oa } N LS a APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENTI FICATI ON APPLICATION &PERMIT BUILDING —ELECTRICAL— PLUMBING — MECHANICAL PERMIT NUMBER 4037 aDLLDINc ADDRESS A wNER'S • NAME I /�� E _ QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION • NDAMERACTORs UTLETS- SWITCHES -RECEP 5.00/1.00 LIGHTING FIXTURES 5.00/1.00 Lie . NO, CONTRACTORS ADDRESS APPLIANCES -RESIDENTIAL 4.00 PANELS 5.00 PHONE DATE OF APPLICATION ARRCHITECT O ENGINEER LIC. No. SIGNS 6.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ADDRESS ENG. CIRCUIT 5,00 PERMIT PERMIT VALIDATION ZIP EMP. METER OR POLE INS. 15.00 !F/- yy RAI /d/3 6^/(�qq ANTS APPLIODRCESS ADORESs MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 - LICENSED CONTRACTORS DECLARATION I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with, Section 70001 of Division 3 of the Business and Professions Code, and my license IS In full force and effect. License Class Lie. Number Dale Cantmclor g6llRNCE DATE C>1 BLOG. ELECT. 0 PLG. MECH: El p p Cit OWNER-BUI LDE R DECLA RATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason, (See. 7031.5, Business and Professions• Code: Any city or county which requires permit to construct, alter, Improve, demolish, or repair any structure, prior to IIS ISSUance, vI50 requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's. License Law (Chapter 9(commencingwith Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and BUILDING PERMIT INFORMATION MISC. — 'REFER TO ORD VALUATION / O -a --D / $/FT. pERMIT ISSUANCE 600 . ELEC.LONTR. LIC. NO. ELEC. TOTAL PERMIT TO /l t QTY. PLUMBING PERMIT FEE TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5TORIES by any applicant for a permit subjects the applicant tea civil penalty of not more than five hundred dollars ($500).) . ��� ALTER -DRAIN -WATER (EA.) 4.00 ❑ I, as owner of the property, -Or my employees with wages as their Sole compensation, will do the work, and the structure is not BACKFLOW PROTECT. DEVICE 2100 OCC. GROUP RES. urvtTS ROOF, AREA, EA,CON D. 4.00 intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR, Code: The Contractor's License Law does not apply to an owner of - , FIXTURES - PER TRAP 4.00 SO, FT. FLOOR AREA TOTAL ACREAGE property who builds or improves thereon, and who docs such work himself or through his own employees, provided that such improve, are not intended or offered for sale, if, however, the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00 'ments or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or in, prove for purpose of sale.).RES CI as owner of the property, am exclusively contracting with GAS - EA. SYSTEM -OVER 4 (EA.) 1.00 BUILDING USE IND CON PB Om., ❑ 0 O ❑ INDUSTRIAL WASTE INTER. 20,00 licensed contractors to construct the Irrojeet (Sea 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thercorJand who LAWN SPRINKLERS - 1 INC 5 V.B. 5.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. ton Contsctor'shccuse, Lwitha contmcmr(s)licensed pursuant to the Contractor's Lip se Law. SEWER -SANITARY -STORM EA. 2006/8.00 TRACT NO. PARCEL NO. ❑ ly ryer t der 5 ._�, R&P.0 forth ism �/� WATER HEATER W/VENT 4.00 Dutt ofl;pi=r% _ Owner WATER SYSTEM 4.00 ACC.OATE ACC, FILE NO. WATER TREATING EQUIP. 4.00 WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self -insure, or a cettificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. - copy thereol'(Sec. 3800, Lab.C.). Policy No. Company FIRE SPRINK Y ❑ N ENERGY T-24 Y ❑ N� ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the city inspection division. Applicant - - MISC.REFER TO ORD. CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c. PLG.CONTR. LIC. NO. PLG. TOTAL COMPENSATION INSURANCE (This section need not be completed if the permit is for one V NE] V N� MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars ($100) Or less.) I certify that in the performance of the work for which this per -CITY. nlit is issued, I shall not employ any person in any manner so as ID BUILDING -� /7 .� became subject to the Workers' Compensation Laws of California. Dale' Applicant ALTER OR ADD TO MECH. 4.00 NOTICE TO APPLICANT: If, after making this Certificate of Ex.. e mption, you should become subject to the Workers' Compensation APPLIANCE 4.00 PLAN CHECK provisions of the Labor Code, you nwet,farlliwith comply with such provisions or this permit shall be deemed revoked. FEE AIR HANDLING UNIT (TO 10=C.F.M.) 3,00 AIR HANDLING UNIT (OVER 10,000QF.M.) 5.00 SEISMIC FEE 13" CONSTRUCTION LENDING AGENCY 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. 3097, Civ.C.). MICROFILM , HEATING UNIT (TO 100,000 B.T.U.) 4.00 HEAT[ NG UN IT IOV ER 100,000 B.T.U.)7.50 ELECTRIC Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ` ordinances and.state laws relating to building construction, and VENTILATION FAN (SINGLE) 3.00 PLUMBING - - - BOILER-(XJMPI3 H. P. Or 100,000 B.T.U.) 4.00 ' BOILER -COMP IOver 100,000 BTU) SEE FEE SCH. MECHANICAL r hereby authoriic representatives of this city to enter upon the above-mentioned properly for inspection purposes. MISC. - REFER TO ORD. CONST. TAX .' (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which ntuy in any w0 mcoune against Said City in consequence of the PERMIT ISSUANCE 3.00 oI It ermit. 1 MECH. CONT.p� LIC. NO. �� ^ MECH. TOTAL TOTAL I orate 'Applicani/Con(racrrr Date OFFICE COPY