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6984APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION'. .APPLICATION '& PERMIT BUILDING — ELECTRICAL— PLUMBING — MECHANICAL PERMIT NUMBER ^ b 984 BUILDING ADDRESS - 5 L _ C 3 Ow 'S NAME 5 / PHONE05 AS' QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION J' 1" /(r - DATE OF APPLICATION CONT UTLETS- SWITCHES -RECEP 5.00/1.00 LIGHTING FIXTURES 5.00/1.00 CONT EACTofls ADDREss ' -6 z o K ,// DNE�Oq,5 PPLIANCES- RESIDENTIAL 4.00 PANELS 5.00 ARCHITECT" on ENGINEER LIC. NO. SIGNS S.00 PLAN CHECK FEE P.L. NO. SIGNS TRANS. 3.00 ADDRESS ARCH OR ENG. • ZIP $PECIALCIFICUIT 5.00 PERMIT VALIDATION --_2- TEMP. METER OR POLE INS. 15.00 ArS ADDRESS OHEss - MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 / LICENSED CONTRACTORS DECLARATION I hereby affirm that 1 am licensed under provisions of Chapter ISSUANCE DATE (commencing with Section 7000) of Division 3 of the Business and Professions Co 4�s yIp0py'Iy full fureq+pQryf cy License Class `L"{[.mber ,,,]`i t10 Y� BLDG. ELECT, 1:1 ❑ PLG. MECH. ❑ ❑' Dme__-/_}_/��Z�Coal maor�at.},q]'7� BUIL•DINS•„PERMIT INFORMATION OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law forthe following reason. (Sec. 7031.5, Business and Professions Code: Any city or county which requires permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also 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 (commencing with 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 MISC. — REFER TO ORD VALUATION / 5( �}t 1 Y f 11 S/FT. Q. v j a PERMIT ISSUANCE' 600 ELEC. CONTR. LIC. NO. ELEC. TOTAL PERMIT TO e QTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant to a civil penally of not more than five hundred dollars ($500).): ALTER -DRAIN -WATER (EA.) 4.00 01, as owner of the property, or my employees with'wages as sole compensation, will do the work, and the structure Is not BACK FLOW PROTECT. DEVICE 2,00 OCC. GROUP- RES. UNITSthen DRAINS -FLOOR, ROOF, AREA, COND. 4.00 intended or offered for Sale (Sea 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 docs such work F IXTUR ES - PER TRAP 4.00 a0. FT. FLOOR AREA TOTAL ACREAGE himself or through his own employees, provided that such improve- mentsarenotintendedoroffered for sale. If, however, the building GAS - EA. SYSTEM - I INC. 4 OUTLETS 4.00 or improvement is sold within one year of completion, the owner- builder will have the burden of proving that h e did not build or im- prove for purpose of sale.). - ❑ I, as owner of the property, am exclusively contracting with . .. GAS - EASYSTEM -OVER 4 (EA) ' 100 BUILDING USE RES IND CON PB OtM1ar '❑ ❑ ❑ ❑ ❑ INDUSTRIALWASTE INTER. 20.00 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 LAWN SPRINKLERS- 1, INC 5 V.B.-5.00 LAWN SPRINKLERS -OVER 5 IEA:) 1.00 ASSESSOR —PARCEL NO. , contracts for such projects with a contmelorfs) licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT NO. PARCEL NO. ❑ l am exempt under Sec,., B.&P.C. for this rcasms WATER HEATER W/VENT 4.00 owner Date WATER SYSTEM 4.00 ACC.DATE ACL. FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP.f? ,4.00 I hereby affirm that 1 have a certificate of consent to --- ----- _ or a certificate of Workers Compensation Insurance, or a certified - 1 ZONING ENG. SITE NO. copy thereof (Sec. 3800, Lab.C.). .. Policy No. Company - - FIRE SPRINK Y ❑ N❑ FLOOD ZONE ENERGY T-24 V ❑ IN C:] A.L.U.C. ❑ Certified copy is hereby furnished. .(Certified co rs 11104 with city 1 rection division. Applicum_�y717f� F L MISC.- (RFI P�[OiORD. CERTIF ATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 re PLG. CONTR. LIC. NO. PLG. TOTAL / COMPENSATION INSURANCE IT his section need not be completed if the permit is for one Y IN E] Y❑ N❑ OTV: MECHANICAL PERMIT FEE FEE SUMMARY' hundred dollars IS 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 manner So as to BUILDING become subject to the Workers' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Ek- ALTER OR ADD TO MECH. 4.00 APPLIANCE 4.00 PLAN CHECK emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Comply.with such provisions or this per shall be deemed revoked. FEE AIR HANDLING UNIT (TO 10,000C.F.M.) 3.00 AIR HANDLING UNIT (OVER 10= C. F.M.) 5.D0 SEISMIC FEE .4S -S 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.ILM 3097, Cie.C.). EXHAUST HOOD (WITH DUCT)' 2.00 MICROF , - HEATING UNIT (TO 100,000 B.T.U.) '4.00 HEATING UNIT (OVER 100,000 B:T.U.)7.50 ELECTRIC Lender's Name Lender's Address I certify that l have read this application and slate that the above information is correct. 1 agree to comply with all city and county lb ordinances and state laws relating to building construction, and VENTILATION.FAN(SINGLE) 3.00-- PLUMBING BOILER -COA'4r (3 H.P. Dr 100,000 B.T.U.) 4.00 BOILER -COMP IOvar400,000 BTU) SEE F EE SCH: MECHANICAL hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. MISC. - REFER TO ORD. - CONST. TAX (We) agree ro Save, indemnify and keep' harmless the City of Cupertino against liabilities, judgments, casts and expenses which may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 3.00 - CONT. a LIC. NO. MECH. MECH. ' TOTAL TOTAL �S grayling this permit. Sign of Applic tractor Dahe ,OFFICE COPY