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3092 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PE MBER HOLDING APPLICATION & PERMIT 3092 ADORES s O BUILDING — ELECTRICAL—PLUMBING —MECHANICAL 0 NER'a - - - PLAN CHECK VALIDATION NAME A�f 1 OTY. ELECTRIC PERMIT FEE G.L /fti/L W,C-BN PHONE CONTRACTORS a X NAME LQ' � /, UTLETS-SWITCHES-RECEP 5.00/1.00 uc.NO. 24`� LIGHTING FIXTURES 5.00/1.00 C,ONTRACTOR's . - ADDRESS APPLIANCES-RESIDENTIAL 4.00 ePHONE (�� PANELS 5.06 DATE OF APPLICATION ORC ITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO. ENGINEER uc.No. SIGNS TRANS. 3.00 noon'E OR ENG. SPECIAL CIRCUIT S.QQ PERMIT VALIDATION SS ZIP EMP.METER OR POLE INS. 15.00 S APPLICANTS MOTORS SEE FEE SCH. AOOR ESS SERVICE CHANGE PAIn 10.00 �1 /� WoM LICENSED CONTRACTORS DECLARATION ld as is u 1 hereby affirm that I am licensed under provisions of Ch:mtcr 9JAN 2 ISSUANCE DATE H C w (commencing with Section 7000)Of Division 3 of the Business and — BLDG. ELECT. PLG. MECH. F N z Professions Cod' d Iy license is in full r NX-4 of ❑ © ❑ ❑ Z, O m— License Class Li, Number�] City Of Co 9 N r D Dare _ Contractor {P 1 Cupertino a m f BUILDING PERMIT rt w u OWNIi R-BUILDER U6CLA '1 O INFORMATION F. ;LL w 1 hereby affirm [hal I am exempt from the Contractor's License MISC.— REFER TO ORD H u O¢ Law Im the following reason.(Sec.7031.5,Business and Profession6 00s PERMIT ISSUANCE VALUATION S/FT. al y0­a' Code:Any'city Orcounty which requlresa permit loconstruct,atler, - ec 2 Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NQ ELEC. , requires tire applicant NOT Such permit to IIIc a signed statement that TOTAL /f/ w$ PERMIT TO he is licensed pursuant to the provisions of the Contractor's License T H ¢Q Law(Chapter 9f commencing with Section 7000)o'Division 3 ofthe 4 o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE ¢ Hp the basisforthealleged exemption.Any violation ofSection7031.5 STORIES TYPE CONSTR. by any applicant fora permit subjects lire applicant to"civil penally gLTER-DRAIN&VENT-WATER (EA.) 4.00 of not more than five hundred dollars(S500)J: ❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS their sole compensation,will do the work,and Bre structure is not intended or Offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00 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 4.00 SQ FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- mentsarenet intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE builder will have the burden of proving that he did not build Or for RES IND INGCON PB Other prove for purpose of sale.). INDUSTRIAL DUSTR I A L W ASTE INTER. 20.00 ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors m construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. and Professions Code',The Contractor's License Law dues not apply to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts fur such projects with a eontraco (s)licensed pursuant to the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO. ❑ lam exempt under Sec.—,BAP.C.for this WATER HEATER W/VENT 4,00 reason Date Owner WATER SYSTEM 4.00 ACC.DATE ACG.FILE NO. WORK ERS'COMPCNSAT ON DECLARATION WATER TREATING EQUIP. 4.00 1 hereby affirm that I have a certificate of consent to sell-insure, ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a en 'ficA copy thereof(See.3800,Lab.C.). Policy No. CompanY Q Q Certified copy is lmreby fu noir . FIRE SPRINK ENERGY T 24 Z Z ❑ Cerlifi d y i tiled its m inspection division. MISC.- REFER TO ORD. Q Applicant Y❑ NE] Y ❑ N❑ W CERTII TI OF ISXEMPFION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOOZONE A.L.U.C. LU > O MPENSATION INSURANCE! PLG.CONTR. LIC.NO. PLG. 0 2 (This section need not be completed if the permit is lot one TOTAL v❑ N❑ Y ❑ N❑ hundred dollars(S 100)or IessJ L) O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY LL 1- mil is issued,I shall not employ any person in any manner so as,to O W become subject to the Workers'Compe"sation Laws of California. BUILDING a Date—Applicant ALTER OR ADD TO MECH. 4.00 } m NOTICE TO APPLICANT: If,after making this Certificate of Ex- 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 FEE U such provisions or this permit shall be deemed(evoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 r the perfonanee of the work for which this permit is issued(Sec. MICROFILM 3097,Civ.C.). - _ HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50 Lender's Address ELECTRIC I certify that 1 have read this application and state that be above VENTILATION FAN (SINGLE) 3.00 information is correct. I agree to comply with all city and county BOILER-COMP13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING ordinances and stale laws relating to building construction, and I' hereby enti oed representatives of this city to enter upon tha BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL above-mentioned properly for inspection purpous. ' (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,jydgntents, costs and expenses which CONST.TAX may in an way a accrue a st PERMIT ISSUANCE 3.00 Y Y Y g Y in consequence of the grunting of[ 7s penult MECH.CONT. LIC.NO. MECH. _ -cs OTA` TOTAL Signals I :int G ntracmr Dutc OFFICE COPY