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C 5696 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU I LDING PROJECT IDENTIFICATION - PERMITNUMBER ADDRESS APPLICATION & PERMIT ��/ BUILDING —ELECTRICAL—PLUMBING—MECHANICAL56-96 PLAN CHECK VALIDATION NAME CITY• ELECTRIC PERMIT FEE ONE CONTRACTOR NAME OUTLETS-SWITCHES-RECEP 5.00/1.00 R No. ' LIGHTING FIXTURES 5.00/1.00 ii;UNTRACTORS' AopREssE PPLIANCES-RESIDENTIAL 4.00 19 0 EsNELS 5.00 agCHITEC GATE OF APPLICATION OR SIGNS - 6.00 PLAN CHECK FEE P.C.NO. ENGINEER AENG. LI O. SIGNS TRANS. 3,00 - ADDRESS ogcss SPECIAL CIRCUIT � 5.00 PERMIT VALIDATION 1 P / EMP.METER OR POLE INS. 15.00 ADDRESS rs SEE FEE SCH. AOg E55 MOTORS -' 1 SERVICE CHANGE 10.00 �/J wzz o/li Foo LICENSED CONTRACTORS DECLARATION ¢i W I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE m w¢ u (comencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. F�i Professions Col an my license is in full force a yeffec3, 2 o L— Date Con Number 7 fr 470 ❑ ❑ ❑ ❑ o m F w Date- _Conlmclor -q 1")-C.✓ �p /=��L ¢ Y 2 J - // O 7 / A ag D, c ce OWNER-BUILDER DECLARATION BUILDING PERMIT 'Xu;LL N " 'I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD INFORMATION F LL o¢ Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT. �wve_1 Code:Any city or county which requiresa permit to construct,alter, PERMIT ISSUANCE 6.00 ©d '2� ae C ¢ p improve,demolish,or repair any structure,prior l0 its issuance.also ELEC.CONTR, LIC.NO. ELEC. O R requires the applicant for such permit to file a signed stmement.that TOTAL 4 f e w m a he is licensed pursuant to Ilse provisions of The Contiactor'i License PERMIT TO ' FZQ �Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE T R=$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. a �� by any applicant for a'permit subjects the applicant loa civil penalty ALTER-DRAIN -WATER (EA.) q,BB p OD of not more than five hundred dollars($500t): ❑ 1,as owner she properly,or my emploBACK FLOW PROTECT. DEVICE their sole compensation, LL Yeas with wages as ion,will do the work,and the structure is not 2.00 OCC.GROUP RES.UNITS intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. q.00 Code:The Contractor's License Law does not apply to an owner of properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 sa Pr.FLOOR AREA rorwL ACREaeE himself or through his own employees,provided that such impowe, mems are not intended cluttered for saleif,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4,00 or improvement is sold within one year of completion,the owner, builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 IEA.) 1,00 BUILDING USE Prove for 1.aso neeose of stheJ. INDUSTRIAL WASTE INTER. P000 RES IND CON PB Oram ❑ d as owners the properly,am exclusively contracting with ❑ D � ❑ ❑ licensed contractors: construct the.project(Sec.7044,Business LAWN'SPRINKLERS--1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. and Professions Code:The Cnntmclor's License Law dues not apply to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a contractor(a)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO. reason re❑ t am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00 Owner Date WATER SYSTEM 4,00 ACC.DATE ACC.FILE NO. , WORKERS'COMPENSA'TION DECLARATION WATER TREATING EQUIP. 4.00 ' 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(her f(Sec.3800 LAC.) PolicN 13 Cerpapy ,.I a^cl ifed copy is hereby furnished. Z Z [L-Cersi d copy is filed with city inspection division. FIRE SPRINK ENERGY T-24 O Applicant MISC.- - REFER'TO ORD. Y N� v ❑ N[:] Ir rn CERTIFICATE.01'EXEMPTION FROM W KERS' PERMIT ISSUANCE 6.00 . W FLOOD ZONE A.L.U.C. > COMPENSATION INSURANCE PLG (1-❑ PLG. =) Z 1ulne .CONTR. LIC.NO.section need not he completed if the permit is for one TOTAL v N� V E] NE]N U O hundred dollars IS 100)or less.) I certify that in the performance of me work for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL t- 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. y Date Applicant ALTER OR ADD TO MECH. , 4.00 BUILDING >_ ED NOTICE TO APPLICANT: If,after making this Certificate of fix. r F-. 2 emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 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(TO 10,C)MC.F.M.) '3.00 FEE CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER IOAOOC.EM.) 5.00 SEISMIC FEE_ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. EXHAUST HOOD(WITH DUCT) 2.00- MICROFILM 3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lender's Name Lender's Address HEAT[NG U N IT(OV ER 100,000 B.T.U.17.50 ELECTRIC I certify that I have read this application unit state that the above VENTILATION FAN (SINGLE) 3.00 x information is correct, 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.) 4.00 hereby authorise representatives of this city to enter upon the above-memioncd property I'or inspection purposes. BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL (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 said City in consequence of the PERMIT ISSUANCE 3.00 granting of this pcnniL MECH.CONT. LIC.NO. MECH. TOTAL TOT ,��T. AL �I 00 Slgnaturc of ApphcunlZon[mclor 'Date OFFICE COPY