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1423I A APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY/,;i BH I LDING PROJECT I DENTIFICATI ON APPLICATION &PERMIT 'BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PRM aER 142 A eG) �F BDItDING �7 y aooRE L 6qs OWNER'S NAME PHONE CITY. ELECTRIC PERMIT FEE- PLAN CHECK VALIDATION ' DATE OF APP LIGATION NgMraRACTORs LIC. No.•/ UTLETS-SWITCHES -RECEP 5.00/1.00 LIGHTING FIXTURES 5.00/1.00 CONTRACTOR'S AODqHH E�sAs Fra. /�� '�,�//,,// '%/�p 17 Fra. �� �IE_Y'PHONE 9`r"'4AO v PPLIANCES- RESIDENTIAL 4.00 PANELS - 5.00 ORRcertecT ENGINEER LIC. No. SIGNS - 6.00 PLAN CHECK FEE P.C. N0. SIGN A _ 3.00 ARCH. OR ENG. ADDRESS' ZIP -No SPEC C 5.00 PERMIT VALIDATION / /i . ISSUANCE DATE EMP. T R OR P I S. 15.00 APPLICANT'S ADDRESS (J MOTO SEE FEE SCH. SERVICE CHANGE • 10.00 LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with. Section 7000) of Division 3 of the Business and Professions Codtyvn �a�y license is in full fore}A• uI J IT 1 . in License Class ��LL Li,. Numbest Dote /2. R.2. g/ Contractor q - BLDG. �'El ELECT. PLG. I MECH. Io•I ❑ L4 OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason. (See. 7031.5, Businessand Professions Code: Any city or county which requires itpermit to construct, alter, improve, demolish, of repair any structure, prior t0 its issuance, also requires the applicant for such permit Io file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law. (Chapter 9 (commencingwitb Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars fb500)J: ❑ 1, as owner of the property, or my employees with wages us their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- m merits are not intended or offered for sale. If. however, the building or improvement is sold within one year of completion, the ownery builder will have'the burden of proving that he did not build or im- prove for purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a contract orfs) licensed pursuant to the Contractors License Law. ❑ I am exempt under Sec.-, BAP.C. for this reason i BUILDING PERMIT INFORMATION MISC. - - REFER TO ORD VALUATION $/FT. PERMIT ISSUANCE 6.00 ELEC. CONTR. LIC. NO. ELEC. TOTAL PERMIT TO DTV. PLUMBING PERMIT FEE STORIES TYPE CONSTR. ALTER -DRAIN -WATER (EA.) 4.00 BACK FLOW PROTECT. DEVICE 2.00 Dcc. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 4.00 FIXTURES - PER TRAP 4.00 SO, FT. FLOOR AREA TOTAL ACREAGE ' GAS -EA. SYSTEM -11 NC. 40UTLETS 4.00 GAS - EA. SYSTEM -OVER 4 IEA.) 1.00 BW LDING USE ' RES IND CON PB Omer ❑ ❑ ❑ ❑ ' ❑ INDUSTRIAL WASTE INTER. 20.00 LAWN SPRINKLERS - 1 INC 5 V.B. 5.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. , SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT NO. PARCEL NO. WATER HEATER W/VENT 4.00 Date Owner WORKERS'COMPENSATION DFCLARAT ION I hereby affirm that I have a certificate of consent to self -insure. or a certificate of Workers' Compensation Insurance, or a certified copy Iherc/�, Policy o WATER SYSTEM- 4.00 ACC.DATE ACC. FILE NO. WATER TREATING EQUIP. 4.00 ZONING ENG. SITE NO. ' ❑ Certifiedc y is hereby for 'l ed. AppCerti(iep c y is led' t the city inspection division. A ,Cg! CER 1F1CA :OPE -MP N PROM WORKERS' CONIPF- TION INSURANCE (This section need not be completed if the permit is for one h undred dollars (S 100) or less.) I certify that in the performance of the work for which this per- mit is issued, I shall not employ any person in any Insurer so is to become subject to the Workeri Compensation Laws of California. Date ApplicantALTER.OR NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a Construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ.C.), Lender's Name FIRE SPRINK Y N ❑ ❑ ENERGY T-24 V N ❑ ❑ MISC. - REFER TO ORD. PERMIT ISSUANCE - 6.00 FLOODZONE Y ❑ N❑ -A.L.UG. Y ❑ N❑ PLG. OONTR, LIC. NO. PLG, TOTAL QTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING ADD TO MECH. 4.00 APPLIANCE 4.00 PLAN CHECK FEE AIR HANDLING UNIT (TO 10=C.F.M.) 3.00 gTtr AIR HANDLING UNIT(OVER 10,000C.F.M.) 5.00 SEISMIC FEE. EXHAUST HOOD (WITH DUCT) 2.00 MICROFILM Cy HEATING UNIT (TO 100,000 B.T.U.) 4.00 D HEATI NG UN IT (OV E R 100,000 B.T.U.) 7.50 ELECTRIC Lenders Address 1 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 hereby authorise representatives of this city to enter upon the above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep, harmless the City of Cupertino a t liabi " s, judgments, costs and expenses which2 may in a y ac a against said City in consequence of the 'grant'n f s - VENTILATION FAN (SINGLE) 3.00 PLUMBING . ,.' BOILER=COMP13'H.Por 100000 B.T.U.) 400 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. - MECHANICAL - MISC. - REFER TO ORD. CONST. TAX , PERMIT ISSUANCE 3.00 J MECH.CONT. - LIC. NO. 3 MECH. '1 TOTAL �f/ O TOTAL Sig afore of Appy C tractor Date EA OFFICE COPY