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6278 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL,POINT,.PEN ONLY BUILDINPERMIT NUMBER BUILDING G'PROJECTlDENTIFICATION APPLICATION & PERMIT - , - AnDRESE u BUILDING—ELECTRICAL—PLUMBING—MECHANICAL , ER' PLAN CHECK VALIDATION NAME CITY. ELECTRIC PERMIT FEE PHON ie;Vaj:� "ON RACTORs UTLETS-SWITCHES-RECEP • 5.00/1.00 -IC,N LIGHTING FIXTURES 5.00/1.00 CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 ADDRESS I /T�II PHON �/ PANELS 5.00 DATE OF APPLICATION RCHITECT SIGNS S.OU PLAN CHECK FEE .C.NO. OR ENGINEER , LIC.NO. SIGNS TRANS: 3.00 ARCH.OR E"o ' SPECIALCIRCUIT' 5.00 PERMIT VALIDATION zip' EMP.:METER OR POLE INS. 15.00 ADDRESS MOTORS - SEE FEE SCH. ADDRESS - JVCJ. SERVICE CHANGE.; 10.00 /Q woo LICENSED CONTRACTORS DECLARATION P/ Q u U 1 hereby affirm that I am licensed under provisions of Chapter 9 - - ISSUA CE DATE ' commrncing with Sce ion 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. r w i rofessions Code ad sss��y license is in full fo e f c ❑ ❑ ❑ o O,n— Date 'lass Contract. on Nwnbe - w h w Lice Lnn l mer -. ams -+ BUILDING PERMIT o: ¢ OWNER-BUILDER DECLARATION a o . 0 MISC.— _ .,REFER TO ORD INFORMATION w . o r• I hereby affirm that I am exempt from the Contrad P s License _ VALUATION E/FT. FUOa Law for the following reason.(Sec.703L5,Businessand Professions PERMIT ISSUANCE -} - Code:Any city or county which requires a permit to construct,alter, 6.00 ¢ 2¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. D LL requires the applicant for such permit to file a signed statement Iha( - 'a TOTAL PERMIT TO R ce he is licensed pursuant to the provisions of the Contractor's License �- F z a Law(Chapter 9(commencing with Section 7000)of Division 3 of the ��rit-�"o, Business and Professions Code)or that he is exempt therefrmn and CITY. PLUMBING PERMIT FEE K F o the basis for the alleged exemption.Any violation of Sectioa7031.5 STORIES TYPE CONSTR. i 3 i° by any applicant for a permit subjects the applicant Toa civil penalty of not more than five hundred undd delta. S500)J: ALTER-DRAIN&VENT-WATER (EA.) 4.00 ❑ 1,as owner of the property,or my employees with wagesas BACK FLOW PROTECT. DEVICE 2,00 occ.GROUP RES.UNITS their sole compensation,will du lite work,and.the structure Is not intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF;AREA,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 50.FT.FLOOR AREA TOTAL ACREAGE • me ntmlf or through his own employees,provided that such improve- oy mei arc not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS4.00 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE - builder will have the burden of proving That he did not build or im- RES IND CON PS Omar prove for purpom of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ I,as owner Of the property,am exclusively contracting with ❑- ❑ ❑ ❑ ❑ licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I IN 5.00 ASSESSORS PARCEL NO. 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-OVER 1,00 contracts for such projects with a contractors)licensed pursuant to the Contractor's License Law. SEWER-SANITARVS A( DO TRACT NO. PARCEL NO. ❑ I am exempt under Sea ,B.&P.C.far this WATER HEATER W/ E 4,00 mason Owner Dale WATER SYSTEM 00 ACC.DATE ACC,FILE NO. WORKERS'COMPENSATION DECLARATION WATER.TR EATING EO P. 4.00 I hereby dfon that I have a certificate ofconsenl to self-insure. ZONING ENG.SITE NO. or a certificate Of Workers'Compegentino Insurance,or a certified _ copy Ihereof(See.3800,Lab.C. �Ie� Policy No. Company ��-0u�. 0' ❑ Certified copy is Hereby recrushed. FIRE SPRINK ENERGY T-24 Z 2 ❑ C 1"- p filed with lire 'Hy i spection divi' n. MISC.• REFER TO ORD. APPHLc PL , L� Y❑ N❑ Y ❑ No � y Clift'fIFICATIi OF IiX1iMPTION FROM 11. PERMIT ISSUANCE 6.00 P� FLOOD ZONE A.L.U.C. W _> COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLO. '` n' 0 (This section need not be completed if Ilse permit,is for one TOTAL w Y❑ N❑ Y❑ N❑ 0 Z hundred dollars(5100)or less.) . U Q 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY - LL H mil is issued,-I shall not employ any Person in any manner se,as to U become subject to the Workers'Compensation Laws of California. 0 0. Dam Applicant - ALTER OR ADD TO MECH. 4.00 BUILDING } tA' NOTICE TO APPLICANT: If,after making this Certificate of Ex- F Z mnption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK , provisions of the Labor Code, you must lorthwillm'comply with FEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10000GF.M.) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MIC—F.M.) 5.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 the performance of the work for which this permit is issued(Sec. MICROFILM 3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC Lender's Address I certify that I have read lhisapplication and slate that the above VENTILATION FAN (SINGLE) 3.00 information is correct.'I agree to comply with all city and county PLUMBING /U �• ordinances and state laws relating to building construction, and BOILER-DOW(3 H.P.or 100,000 B.T.U.) 4.00 hereby authorize representativesof this city to enter upon.the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments,costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX may in any way accrue against said City in con"itunce of the granting of this per MECH.CONT. LIC.NO. MECH.' TOTAL TOTAL g azure pFyficanTCcm tractor Dem OFFICE COPY