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14395 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUI'LDI NG PROJECT I DENTI FICATION PERMIT NUMBER - BUILDING APPLICATION & PERMIT '�(j J AbORES.S • 4 J L "4P ldx.9 BUILDING-ELECTRICAL-PLUMBING -MECHANICAL OWNER'S , PLAN CHECK VALIDATION rvn/ , MJE /J QTY. ELECTRIC PERMIT FEE CONTRACTOR'S NAME 1 UTLETS-SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 CONTRACTOR'S [INPPLIANCES-RESIDENTIAL 4.00 ADDRESS J7 ae ��JJ�� JJhJ/✓✓ Ljr,7 PANELS 10.00 DATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. Ofl ENGINEER LIC.No. SIGNS TRANS. •3.00 ARCH.OR ENG. 500 PE EMIT VALIDATION ADDRESS SPECIALCIRCUIT , ZIP EMP,METER OR POLE INS. 20.00 ADDRESS AMOTORS SEE FEE SCH. DRESS E55 � `A SERVICE CHANGE 20.00 0 ,09 LICENSED CONTRACTORS DECLARATIONF 7(`7 <v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUAN CE DATE'/ w Q w (commencing with Section 7000)of Division 3 of the Business and L .ELECT. PLG. MECH. w'^ Professions Code,�an�d�nn license is in full force and cUe-L Z i m o License Class Lie,Number ;2(V L� ❑ ❑ ❑ Dalc�9Contreclnr�__`/ / !_..y/.-tea a Y w . a -BUILDING PERMIT ¢ ¢ ¢ OWNER-BUILDER DECLARATION INFORMATION We, MISC.- REFER TO ORD X 3 N I hereby affirm ilal 1 s. exempt from the I co.Contractor's License VALUATION S/FT. u0a Law for the following reason,(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 fwCode:Any city or county which requires a perouto construct,atleq ELEC.CONTR. LIC.NO. ¢ ¢ ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC. - 0 u requires the applicunl for such permit to lite a signed statement that TOTAL _ PERMIT TO a w 9 he is licensed pursuant to the provisions of the Contractor's License H z r Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe Gr� - e Business and Professions Code)or that he is exempt Therefrom and GTY. PLUMBING PERMIT FEE .- (S the basis for the alleged exemption.Any violation nf$eclion 703 1.5 1 STORIES TYPE CONSTR. e- by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars(5500).): ❑ If is 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 of offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's License Law docs not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SEE FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve. ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 or improvement is sold within one year of Completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2,00 BUILDING USE builder will have the burden of proving that he did not build or int- i prove for propose of sale.). RES IND CON PB :Other r INDUSTRIAL WASTE INTER. 30.00 ❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ .13 •. licensed contractors to construct lire project(Sec. 7044,Business LAWN SPRINKLERS-A INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Code:The Contractor's License Law docs 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 contractorts)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO. ❑ lam exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00 reason Owner Duce WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKF-RS'COMPENSATION DECLARAl'ION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent to sell-insure, ZONING or a certificate of Workers'Compensation Insurance,or u certifiedENG.SITE NO. copy thereof -((S--e``'.388-00,}J.uy,C�)�.� Policy N MnebyJ Q ❑ C.Rdjed cors hereby furnsshe FIRE SPRINK ENERGY T iA Z APP❑licCet- ropy is RIC With the city inspection division. = REFER TO ORD. f MISC. Y❑ N❑ Y❑ N❑ ~ wPERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. LEI > frCERTIFICATfi OP EXEMPTION FROM WORKERS' , _ COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. 0• o (This section need not be completed if the permit is for one TOTAL Y❑ NC] Y [:] N❑ 0 Z hundred.dollars($100)or less.) U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F . mit is issued 1 shall not employ any person in any manner so as to U become subject to the Workers'Compensation Lows of California. 0 i Date Applicant ALTER OR ADD TO MECH. 5.00 o BUILDING >_ N NOTICE TO APPLICANT: If,after making this Certificate of Ex- , L.. ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE, U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10,000C.F.M-) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for 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 MICROFILM 3097;Civ.CJ. Lender's Name HEATI NG UN IT ER 100,000 B.T.U.)9.50 ELECTRIC Lender's Address _ I certify that l 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 county PLUMBING ordinances and state laws relating to building construction, and BOILER-CONP(3H.P.or100,000B.T.U.) 6.00 �s hereby authorize representatives of (his city to enter upon the a CTw above-mentioned property for inspection purposes: BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL v c- (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, Costs and expenses which /O OD CONST.TAX may in y way accme ainat said City in consequence of the PERMIT ISSUANCE 10.00 an ranting Of this p•rmil. MECH.CONT. LIC.NO. MECH. ' `^I/ / / ,a ��/ TOTAL B pp X/ .� y1 ,,*f ✓� a.+.L��L7fi3 /�.S�o7J TOTAL Signature ofA Iicani/ for' Date OFFICE COPY