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09947 APPLICANT'TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY - E BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION &'PERMIT O A 4 oDRESS 1Q/40-101. 72 BUILDING.-77:tELECTRICAL-PLUMBING-MECHANICAL OWNER'S ��NAn19 A-9 P�� - PLAN CHECK VALIDATION QTY. ELECTRIC PERMIT FEE PHONE CONTRACTOR'S S t UTLETS-SWITCHES-RECEP 10.00/1.00 LIC,NC LIGHTING FIXTURES 10.00/1.00 CONTRACTORS ONr, TRAS ns ADDRESS , PPLIANCES-RESIDENTIAL 4.00 Z,Cre y PANELS 10.00 DATE OF APPLICATION RCNrtscT PANELS (OVER 200 AMP) . PLAN CHECK FEE OR 2606 P.C.NO. O ENGINEER LIC.NO. SIGNS TRANS. 3.00 ADDRESS ENG. SPECIAL CIRCUIT 5.06 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 PAID noon ANTS MOTORS SEE FEE SCH. s p J SERVICE CHANGE 20.00 OCT 23 1985 w 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City �p(��,,,,.y u u 1 hereby affirm that I am licensed under provisions of Chapter 9 yl'+-Y$SJR71CQ10 waw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. mH. D i Professions Code,and my license is in full force and effect. ❑ ❑ ❑ . o i v'1 o License Class Lic.Number F m s.j Dale Contractor a m I - BUILDING PERMIT s ¢ w u OWNER-BUILDER DECLARATION - INFORMATION X O u m I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD w 3 u VALUATION SIFT. F LL O a Law for the following reason.(Sec.703 L5,Business and Professions PERMIT ISSUANCE 10.00 Code:Any city or county which requires a permit to construct,alter, SE¢w ELEC.CONTR. LIC.NO. 4 o improve,demolish,or repair any structure,prior to its issuance,also ELEC. O ¢ requires the applicant for such permit to file a signed statement that TOTAL - gERMIT TO w$ he is licensed pursuant to the provisions of the Contractor's License F Z>' Law.(Chapter 9(commencing with Section 7000)ofDivislon 3 ofthe 4 c Business and Professions Code)or that he is exempt Therefrom and OTY. PLUMBING PERMIT FEE ' ¢ F $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. a9 ? by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 of not more than five hundred dollars(SS00).): ❑ 1,as 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 or offered for vle (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 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 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 6.00 menti aro not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner- " J builder will have the burden of proving that he did nut build or im- GAS-EA.SYSTEM•OVER 4 (EA.) 2.00 BUILDIN u5E v prove.for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES. IN PB Other El 1,as owner of the property,am exclusively contracting with ❑ El 51 ❑ licensed Contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSOR 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 5(EA.) ' 1.00 contracts for such projects with a contractorls)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00 the Contractor's License Law. TRACT NO. PARCEL NO. ❑ lam exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT. 6.00 ' reason Owner Data WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate ofconsent to self-insure. or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO. copy thereof(Sce.3800,Lab.C.). Policy No. Company Q O Certified copy is hereby fur fished. FIRE SPRINK ENERGY T 24 Z O ❑ Certifie p Is fil 0 ins I +p�ylr division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑ Applicant V Y N V N P: -0 PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. UJ COM LU CERTIFICATE EXEMPTION INSURANCE R 1 ORKERS' A NCE PLG CONTR. LI0.N0. PLG. V❑ N❑ Y ❑ N❑ 1 O hundred action need not be completed if the permit is for one TOTAL L) 0 hundred dollars(S100)pe less.) - LL O I certify that h the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY 0 F mil is issued,e I shall not employ any person in any manneror is to U become subject to the Workers'Compensation Laws of California. i Dute Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } N NOTICE TO APPLICANT: U_after making this Certificate of Ex- I.. Z eruption,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 10MC.F.NL) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DWC.RM.) 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. MICROFILM 3097',Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name Lender's NamAddress HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC 1 certify that I have read this application and stale That the above VENTILATION FAN (SINGLE) 4.00 04 information is correct. I agree to Comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING ordinances and slate laws relating to building construction, and hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,010 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 CONST.TAX may in any way accrue against said in consequence of the PERMIT ISSUANCE 10.00 grant f This perm MECH.CONT. LIC.NO. - MECH. O TO y L TOTAL 5 sure Df Applin no/Contract r 41 1V 7 1 OFFICE COPY