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6926 APPLICANT TO FILL IN INFORMATION WITHIN RED-LINES --!-USE BALL.POINT PEN ONLY a SUI LDI NG PROJECT 1 DENTI FIC TION PERMIT NUMBER aOILDING APPLICATION & PERMIT AOORE55 e 1- 6926 /0/? _ �A BUILDING—ELECTRICAL—PLUMBING—MECHANICAL OWNEe'a + � , ., r PLAN CHECK VALIDATION NAME ,� P�/• Of, ELECTRICPERMIT' '1C NQ�PCN��HONE CONTRACTORS _ UTLETS-SWITCHES-RECEP 5.00/100 T• f LIGHTING FIXTURES 5.00/1.00 \ , TRA ADIRPADTODs DPPLIANCES-RESIDENTIAL '4.00 X CONy PHONE / PANELS 5.00 DATE OF APPLICATION' ARCHITECT SIGNS 6 PLAN CHECK FEE P.C.NO. ENGINEER LIC.Na. SIGNS TRANS. 3.00 ADDRESS Ervc. PERMIT VALIDATION ADDRESS "• SPECIAL CIRCUIT 5.00 , ,ZIP TEMP.METER OR POLE INS. 15.00 - APPLICANTS - MOTORS -SEE FEE SCH. SERVICE CHANGE 10.00 °1fY' '02 LICESED CONTRACTORS DECLARATION - T_ a v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE N'Q n (commencing with Section 7000)of Division 3 of the Business and eLOG. ELECT. PLG. MECH. H w z Professions Code,and my license is in full force and effects a, D m — License Class('"—.f I Lie.Number ruiEl 10 m f w 'Date ZZ /0=uY Contractor�.}fFYj� L - ¢_m¢< OWNER-BUILDER DECLARATION sh,?'sP BU11:DING�PERMIT os " MISC.—. REFER TO ORD ^°;IINFURMATIUN K I hereby affirm that 1 am exempt from the Contractors License VALUATION S/FT. - F u o< Law for the following reason.(Sec.7031.5,Business and Professions I PERMIT ISSUANCE 6,00 0 Code:Any city or county which requires a permit to construct,alter, .. 6¢Q p improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ' — O u requires the applicant for such permit to file a signed statement that , TOTAL PERMIT TO A a,m m he is licensed pursuant to the provisions of the Contractor s License I_ > Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe 4+°:r.r �- io Business and Professions Code)or that he is exempt therefrom and OTY'. ;:PLUMBING PERMIT EIFFEL.i. a I-o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00 of not mom than five hundred dollars IS 500).1: ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC:GROUP RES.UNITS their sole compensation,will do the work,and the structure Is not intended or offered for sale(Sec. 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 SO.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve. mems are not intended or offered for sale.l f,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4,00 ' or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING uSE builder will have the burden of proving that he did not build or im- .. prove for purpose of sale.). INDUSTRIALWASTE INTER. 20.00 , RES IND CON PB Dsbe, ❑ I;as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ Cl licensed contractors m construct the project(Sec. 7044,Business LAWN•SPRINKLERS-1 INC 5V.B. 5.00 A5SESSOR5 PARCEL NO. and Professions Code:The Contractor's License Law does not apply lO an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.)' 1.00 contracts for such projects with a contractors)licensed pursuant to the Contractor's license Law. - SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO.• PARCEL NO. ❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 4.00 reason Owner Dam WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 1 hereby affirm that I have a certificate of consent In sel Ginsum, ZONING ENG.SITE NO: or a certificate of Workers'Compensation Insurance,or a certified copy the 24 Plic gSe3g0Jti0ty ' m zEO ❑ Certified copy is hereby furnished.' FIRE SPRINK ENERGY T-24 Z Z P Certifiedx copy n ri• w•th a city inspection division. MISC. REFER TO ORD. O APPlicxnt Y\_ ,yi_y�� �.7 - Y❑ 'N❑ Y ❑ N❑ Fy PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c. LU CIiRI'I FICCOI PE EXEMPTION FROM WORKERS' UJ > COMPENSATION INSURANCE, PLG.CONTR. LIC.NO. PLG. CL (This section need not be completed if the permit o for.one TOTAL Y❑ N❑ Y❑ N❑ Z hundred dollars IS 100)or less.) r.-.- C.1 O I certifythat in the crformarce of the work for which this p "^" a FE SUM LL )— mil is Issud,I shall not employ any person in any manner so as to nTIyA.,�,�fi�s1 0 :-;?`MECHANICAL PERM�T�1[,j. ,.. FEE :, _ .=xaa.rm Ow- becnmesubjeet to the Workers'Compensation Laws of California T� - a Date Applicam - ALTER OR ADD TO MECH.. .' 4,00 BUILDING } y NOTICE TO APPLICANT: IL after making this Certificate of 1: F ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 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 10,000C.F.M) ,OQ 1110, CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER tQ(10400,MS 5.00 SEISMIC FEE 1 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. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM 3097,CicC.L Lender's Name Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC I certify that l have read this application and stale that the above zo VENTILATION FAN (SINGLE) 3.00 ,. information is correct. 1 agree to comply with all city and county PLUMBING ordinances and state laws relating to building construction, and BOILER-COMPO H.P.Or 100,000 B.T.U.) 4.00 hereby authorize representatives of this city to enter upon the BOILER-COMP IOve,100,000 BTW 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 3 � CONST.TAX may in any way accrue against said City in consequence of the gmy�g Of this Permit. . MECH.CONT. LIC.NO. MECH. ,0 KS�z� y TOTAL 9 eti TOTAL` Signature of Atplicant/CorilbaCtur Date s OFFICE COPY- ..