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7072 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY OBUILDING PROJECT I DE TIF CATfON PERMIT NUMBER 9UILDING APPLICATION & PERMIT OORF55 . tV'Q BUILDING,-ELECTRICAL-PLUMBING-MECHANICAL 7072 OwrvER " • j PLAN CHECK VALIDATION "AME �` "ELECTfi(C'PERMIT' NOME ACTORS - UTLETS-SWITCHES-RECEP. 5.00/100 LIC.NO. LIGHTING FIXTURES 5.00/1.00 CONTR�CTOR ADDRESS PPLIANCES-RESIDENTIAL 4.00 ADDRESS - PHONE PANELS .5.00. DATE OF APPLICATION ARCM rECT' 600 PLAN CHECK FEE P.C.NO. OR SIGNS . ENGINEE J LIc.NO./���� SIGNS TRANS. 3.00 ARCH.OR ENG.- SPECIALPERMIT VALIDATION ADDRESS CIRCUIT 5.00 ZIP EMP.METER OR POLE INS. 15.00 ,f- APPLIC^NT'S,B,•7 .Ir �/i2r1✓ MOTORS SEE FEE SCH. l ADDRESS LJ CAL A-10VI SERVICE CHANGE L"nI'm 10.00 ¢DO LICENSED CONTRACTORS DECLARATION �•� _ u I hereby affirm Thal I am licensed under provisions of Chapter 9 - ISSUANCE DATE -w Q Ai (commencing with Section 7000)of Division 3 of the Business and J 11 fV � , SLOG. ELECT. PLG. MECH. Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑ z O w License Class Lic.Number Oz F Dale Contractor City of Cupertino ¢ a,s ..BUILDING�PERMIT - - ¢ ¢w a OWNER-BUILDER DECLARATION - INFORMATION o a " MISC.- REFER TO ORD -X ;¢ H 1 hereby affirm that I ran exempt from the CunhuClor's License VALUATION S/FT. a Law for the following reason.(See.7031.5,Businessland Professions PERMIT ISSUANCE 6.00 Code:Any city or commy which requiresa permit to const"et al[eq ¢ ¢Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. ,LIC.NO. ELEC. �/ D ¢ requires the applicant for such permit to file a signed statement(hat TOTAL C; PERMIT TO A w m u he is licensed pursuant to the provisions of(he Contractor's License eLeG7 Uzi Law(Chapter 9(commencing with Section 7000)of Division 3 of the j! r ( ���. a: Business and Professions Code)or(hat he is exempt therefrom and QTY: PLUMBING PERMIT'+ FEE ¢ =$ the basis for the alleged exem lion.An - g p Any of Section 7031.5 •STORIES TYPE CONSTR. d _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.I 4.00 of.nnt more than five hundred dollars(E500LE ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 Dec.GROUP RES.UNITS then sole compensation,will do the work,and the structure Is not t ' '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 TOTALACREAGE himself or through his own employees,provided that such improve- ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00 Or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BuaOWG USE builder will have the burden of proving that he did not build or im- ,RES IND CON PB other pryrfor purpose of sale.). INDUSTRIAL.WASTE INTER. 20.00 11 ❑ ❑ 1-1 C]TAn I,as owner of the property,am exclusively contracting with liL� sed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORSPARCEL NO. and Pruressions Code:The Contractor's License Law does not apply ' to an owner of property who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.). 1,00 contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 .TRACT NO, PARCEL NO. ❑ lam exem senders ,BAP.C.for WATER HEATER W/VENT 4.00 reasoner y�.r�J1f - OwIUV�JI CUa[e WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO. WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO, or a certificate M Workers'Compensation Insurance,or a certified , copy Nlereof(Sec.3800,Lab CJ. ' Policy No. Company O ❑ Certified copy is hereby furnished. FIRE SPRINK- ENERGY T 24 Z p A 0licCertified copy is filed with the city inspection division. MISC.- REFER TO ORD. LY N v N ❑ ❑ ❑ ❑ ~ m PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C. LU - CIiRTIFICATEPF EXEMPTION I PT10N PROM WORKERS' W 7 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. 'PLG. (L Q (This section need not be completed if the permit is for one TOTAL '; Y❑ 'N❑ Y❑ No D Z hundred dolhus(SIOO)or less.) -'e ,x (� O 1 ecrlil' that in the performance of the work for which this per- a :+"FEE$UMMP.RY Y OTky �w . `MECHANICAL'PERMIT:•• r ;,FEE'. LL F mit is issued,I shall not employ any person in any manner so as to - - OO become subject to the Workers'Compensation Laws of California. BUILDING Uate� Applicant' ALTER OR ADD TOWECH. 4.00 } tart NOTICE TO APPLICANT: If,after making this Certificate ofl.... 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=C.F.M.) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.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 HEATING UNIT(TO 100,000 B:T.U.) 4.00 - MICROFILM 3097,Cie.CJ. Lender's Name Lender's NameAddress H EATI NG UN IT(OV ER 100,000 B.T:U-)7.50 ELECTRIC . - L' I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 • information is correct 1 agree comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING ordinances and state laws relatiti ng to building construction, and hereby authorize representatives of this city to enter upon the BOI LER-COMP.(Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property for inspection purposes. _ (We) agree to save, indemnify and kee harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,jud IS, (s and expenses which. CONST.TAX may in any way acct ag'' in copses once the PERMIT ISSUANCE 3.00 'gr a is per / / ECH.CONT. LIC.NO. MECH. TOTAL TOTAL Ig ' 90, pphcan( ntnic r ale OFFICE COPY - .