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9401APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTI FICATION IDENTIFI=CATION APPLICATION &'PERMIT BUILDING -ELECTRICAL- PLUMBING -MECHANICAL - PERMIT NUMBER . 9401 BUILDING ADDREs3�� �% 1. OWNER'S ( Lr{II�YXII PHorve .�,'Zds QTv ELECTRIC PERMIT FEE PLAN CHECK VALIDATION - CONTRACTOR'S NAME OUTLETS - SWITCHES -RECEP 10.00/1.00 uc.ND. LIGHTING FIXTURES 10.00/1.00 noonessToaa -APPLIANCES -.RESIDENTIAL 4.00 PHONE DATE OF APPLICATION PANELS 10.00 OgclsrtacT ENGINEER uo NO. PANELS (OVER 200 AMP) 20,00 PLAN CHELK FEE P.C. NO. ISIGNS TRANS, 3.00 ARCH, OR ENG, ADDRESS SPECIALCIRCUIT 5.00 " PERMIT VALIDATION zip TEMP. METER OR POLE INS. 20.00 T S AP RESS MOTORS SEE FEE SCH. ' 7/ SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP, POLE 30.00 I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license IS In full force and effect. -1�fk/G✓ ISSUANCE ddd ATE ' BLDG. ELECT, PLG. MECH. License Class Lie. Nwnber Date Contractor , OWNER -BUILDER DECLARATION BUILDING PERMIT I hereby affirm that I am exempt from the Contractor's License INFORMATION MISC. - . REFER TO ORD PERMIT ISSUANCEVALUATION 10.00 g/FT. Law for the following reason, (Sec. 7031.5. Business and Professions Code: Any city .,county which requires a 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 slarement that he is IicenseJ pursuant to the provisions of the Contractor's LiceB. ELEC. CONTR. LIC. NO. ELEC. TOTAL PERMIT TO Law(Chapter 9[commencing with Section 7000)of Division3of the Business and Professions Code) or that he is exempt therefrom and the baric for [he alleged a%<mpliom. Aoy violali0n o(Sediop 7031.5 by any applicun[forapermit subjects the apDlican/tuu Civil penally of not more than five hundred Aollars (5500).): nL / Oso OTY. PLUMBING PERMIT FEE - ALTER-DRAIN-WATER(EA.1- STORIES ' TYPE CONSTR. ' ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is trot intended or offered for sale (Sec. 7044, Business end 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- mentcare not in tend ed or offered for sale. If, however, the building or improvement is Sold within one year of completion, the owner - 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 dues not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a contractor(s) licensed pursuant to theContractor'sLicenseLaw. ❑ 1 am exempt under Sec. , BAP.C. for this reason BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP - 'RES. UNITS DRAINS -FLOOR, ROOF, AREA, CON D. 5.00 FIXTURES- PER TRAP 5.00 GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00 GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 SQ. FT. FLOOR AREA TOTAL ACREAGE BUILDING USE RES IND CON Pa Omer ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPR - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. - SEWE NI 4=MEA. 200ft/10.00 TRACT NO, PARCEL NO, WATER HEATER T 6.00 Owner Date WATEOI�,Y§TERnp rfipn 5.00 ACC.OATE ACC. FILE NO. . WORKERS'COMPENISATION DECLARATION - WATER TREATING EQUIP, 5.00 1 hereby affirm that I have a Certificate ofconsent to self -insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab.C.). Policy No. Company. y� /ry LIVE ZONING ENG. SITE NO. _ ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the city inspection division. Applicant "FIRE MI C. • REFER TO ORD. SPRINK Y ❑ N❑ ENERGY T-24 Y [:] N❑ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one PERMIT ISSUANCE ?800 FLOOD ZONE Y C]N ❑ A.L.U.C. Y ❑ N❑ PLG. GONER. LIC. NO. - PLG. TOTAL 0 �_ hundred dollars ($ 100) or less.) QTY. MECHANICAL PERMIT FEE FEE SUMMARY I certify that in the performance of the work for which this per- mil is issued, I.shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after muking,this Certificate of Ex- BUILDING ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 AIR HANDLING UNIT (TO 10MC.F.M.) 4.00 PLAN CHECK FEE ' 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 he deemed revoked AIR HANDLING UNITIOVER 10MC.RM.16.00 SEISMIC FEE - 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.). Name Lender's Name EXHAUST HOOD (WITH DUCT) 5.00 I HEATING UNIT (TO 100,000 B.T.U.) 8.00 MICROFILM Lender's HEATINGUNIT IOVER 100,000 B.T.U.)9.50 ELECTRIC VENTILATION FAN (SINGLE) 4.00 BOILER-OOfYtP 13 H.P, or 100,000 B.T.U.) 6.00 I 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, PLUMBING Q Bad hereby authorize representatives of this city [o enter upon the above-mentioned property for inspection purposes.' BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way, accrue against said City in consequence of the Van f this p rmit. MISC. - - REFER TO ORD. - PERMIT ISSUANCE 10.00 CONST. TAX MECH. CONT. LIC. N0. MECH. ��� TOTAL TOTAL I nature of Appiiant/Contractor Ir Date OFFICE COPY