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6820 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.- USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION .,' PERMIT NUMBER BUILDING r_.. APPLICATION & PERMIT 682 DDREss ^� Q 9fK- �O01I oZ An/u F• BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 0 WNER'ye T_.. QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION NAME li V(DQ�1'T'•l'WO r vla'YEC�/`� • Ro F} C/amwDbE �og Y1 CONTRACTOR S OUTLETS-SWITCHES NAME -RECEP 5.00/1.00 LIC.NO. LIGHTING FIXTURES 5.00/1.00 CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 ADDRESS PHONE PANELS 5.00 DATE OF APPLICATION ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO. OR ENGINEER uc.NO V60I SIGNS TRANS. 3.00 PERMITN. ADDR.SS ENG. a3 7�W¢-©Vx a2 . SPECIAL CIRCUIT 5.00 III ADDRESS AI V llpl(/ S AIV' SC�•�rZ L' 4A-L o`� EMP.METER OR POLE INS. 15.00 APPucANrsi3d•-.7 �� s'UPt(e MOTORS SEE FEE SCH. I ADDR Ess X l .Sj vale G L 7 c)ea SERVICECHANGE 10.00 O o LICENSED CON"TRACTORS DECLARATION a u o I hereby affirm that I am licensed under provisions of Chapter 9 SSUAP'CA DATE G n (commencing with Section 7000)of Division 3 of the Business and BL ELECT. PLG. MECH. o, o z Professions Code,and my Iicdnse is in full force and effect. z o m - License Class Lie.Number 2 z w Datc Contractor a y BUILDING PERMIT'" ¢ ¢ w Q OWNER-RUICDER DECLARATION INFORMATION - Oaca MISC.- REFER TO ORD w3 r 1 hereby affirm that 1 em exempt from the Contractor's License Loa, Law for the tollowing mason(Sec.7031.5,Bd,Rm OxmadPR,fEf,iocS PERMIT ISSUANCE VALUATION $/FT. m Code:Any "t or count which requires t to eoustmet,alter, 6.00 / ce s- y u y y es q Perot _ ELEC.CONTR. LIC.NO. ¢ Q ¢ In1prI1VC,derl101Sh,or repair any 9t[netnrC,prior t0 its 155n0n W,a160 ELEC. - ¢ requires the applicant fur such permit to the a signed statement that TOTAL PERMIT TO w " he is licensed pursuant to the provisions of the Contractor's License r z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe K Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢r oo the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. a ;'m by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN'&VENT-WATER (EA.) 4.00 of not more than tive hundred dollars($5000.): ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 occ.GROUP RES.UNITS their sola compensation,will do the work,and the structure is not intended or offend for sale(SLY. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 Code: The Contractor's License Law docs 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 • himself or through his own employees,Provided that such improves menu are not intended or offered for sale,it,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00 r naprovenrent 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 PB OIM1er pr ve or purpose al'sale.). INDUSTRIAL WASTE INTER. 20.00 El El El 1:1 ❑ I s owner of the property,am exclusively contracting with lice ell contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORSPARCEL NO. and Prolr su ,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 retracts for such projects with It contractor(s)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO. ❑ l am exempt under.cc. ,BAP.C.or this WATER HEATER W/VENT 4.00 cas'on _ owner g Date Ll TWATER SYSTEM 4.00 ACC.DATE ACG FILE NO. WORKERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 4-00 o l hereby affirm that I have a certificate of conxnt to sell-insure, ZONING ENG.SITE NO. a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sce.3800,Lab.C.). Policy No. Company O' CI Cerified copy isbereby furnished. FIRESPRINK ENERGY T-24 Z Z 0 Certified copy is fled with the city inspection division. MISC.- REFER TO ORD. O Applicant Y E] N❑ V [:] N❑ Lr N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.LD.C. 11J > COMPENSATION INSURANCE PLG.CONTH. LIC.NO. PLG. ❑ ❑ ❑Y N Y N d (This section need not be completed if[he permit is for one TOTAL ❑ Z) Z hundred dollars(S 100)or less) v','u^=*^fi"`v** =' 00 1 certify that in the performance of(he work for which this per- CITY. MECHANICAL PERMIT ' FEE -{FEEySONIMARY l.L H DUE is issued,I shall not employ any person in any manner so as to V become subject to the Workers'Compensation Lags of California. ED Date:// /$I�Applicant�i±_�e�Y/� -UAC - LTER OR ADD TO MECH. 4.00 BUILDING ,V } W NOTIC e v) AI PLICANT: II',after making this Certificate of Lx- Z emplion,you should become subject to the Workeri 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 110SMIC-F.M.) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PIMC.F.M.) 5.00 SEISMIC FEE 1 I herehy affirm that there is a construction lending agency 1'or EXHAUST HOOD (WITH DUCT) 2.00 the performance of the work for which this permit is issued(Sec. MICROFILM 3097,Civ.C.L D� �_ P 4161- HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lender's Name !J N Lender's Address III N - .5 c HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 ordinances n correct. I agree to comply b with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING ordinances and stare laws relating to building city and co and hereby authorize repmsentattees of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEE SCH. MECHANICAL above-mentioned property for inspection purposes. (We) agree to save, Role.mify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments -ost and expenses which CONST.TAX may in any uy uccru� uga' i conseque a of the PERMIT ISSUANCE 3.00 g' IS penB' / ECH.CONT. ' LIC.NO. MECH. - TOTAL u}� TOTAL Signature of Applicant/ ontraclo OAK OFFICE COPY