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6817 I r 1 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER NG AD a T APPLICATION & PERMIT v ss / BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6817 OWrvER' !� PLAN CHECK VALIDATION NAME ��Po-'u�-Tu-a �� CITY. ELECTRIC PERMIT FEE (� 1/1 P r� QV O CONTRACTORS NAME UTLETS'-SWITCHES-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 G�-hl) uc.NO. �U� SIGNS TRANS. 3.00 AD , ., PERMIT V�IDATION ADDRESS On OR ENG7� S A4A"V\ Q SPECIAL CIRCUIT 5.00 -S' II52 (Z-VIE-4- TEMP.METER OR POLE INS. 15.00 moo ssTS I30- S. PF4p-.y 5.,, MOTORS SEE FEE SCH. CaL, qag SERVICE CHANGE 10.00 w00 LICENSED CONTRACTORS DECLARATION Q u u I hereby affinn that 1 am licensed under provisions of Chaplcr'l ISSUANCE DATE y a H Iconunrncing wish Section 70001 of Division 3 of the Business aid DL ELECT. PLC. MECH. H Professions Code mW my license is in full force and effect El El License Class Lic.Number �gz Q r w\ Uatc Cantmctor a y fI BUILDING PERMIT w a OWNER-BUILDER DECLARATION � INFORMATION O REFER TO ORD R 3 u- m I hereby affinn that 1 am exempt from the Contractor',Licattt MISC.- LLoj la6 Law for the following reason. 7031.5.Businessand Professions PERMIT ISSUANCE .( VALUATION � - Code:Any city orcounty which requires a permit construct,alter, .00 / ttQ Q improve,demolish,cr repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ©� ai - O u requires the applicant for such permit to file a signed stateroom that TOTAL PERMIT TO n w m he is licensed pursuant to the provisions of the Contractor's License �1 Hzi Law(Chapter 9(commencing with Section 7000)o'Division 3 ofthe a Business end 1'mfcsslons Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE r o the basis for the alleged exemption.Any violation of Section703L5 STORIES TYPE CONSTR. by any applicant tin a permit amjccts till;q,Plicant toaeivil penalty ALTER-DRAIN&VENT-WATER (EAJ 4.00 of nu more than five hundred dollars($500).): . 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 DCC.GROUP RES.UNITS Thur 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 riot apply to an owner of property who builds or improves fiction,and who docs such work FIXTURES PER TRAP 4.00 So.FT.FLOOR AREA TOTALACREAGE himself or through his own employees.provided that such improves mints are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-I INC.4 OUTLETS 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 M1UNen of proving that he did not build at int- RES IND CON PB Other prove for purpose ofsale.). INDUSTRIAL WASTE INTER.'- 20.00 O I,as owner of the property,am exclusively contracting wilh ❑ ❑ ❑ ❑ ❑ licensed IDnlractOrs to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS 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 IEA) 1.00 contracts for such projects with a cuntaCIORs)licensed pursuant to On^Conlractois License Law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT No. PARCEL No. 0 Iamexmnpumdcr S 0 B.&P.C.frlh's WATER HEATER W/VENT 4.00 reason Owner late - WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO. WORT:ERS'COMPHNSATION DECLARATION WATER TREATING EQUIP. . 4.00 t I hereby of to n that I have a certificate of consent to self-insure. ZONING ENG.SITE NO. or a cltificxte of Workers'Compensation Insurance,ora certified copy thereof I Sec.3800.Lub.CJ. ��I Policy No. Compnn - any Q ❑ Cert flied copy is hereby famished. FIRE SPRINK ENERGY T 24 Z ZD Certified copy is filed with Ore city inspersion division. Q Applicant MSC.-_ REFER TO ORD. v [:] ❑ N v N ❑ ❑ ~ va PERMIT ISSUANCE 6.00 FLOODZONE ' A.L.U.C. Er CISRT'ErIGATIi OE EXEMPTION FROM WORKERS' W >_ COhI I'fiNSATION INSURANCE URANCE PLG.CONTR. LIC.NO. PLG. CL O ('fits section need not be completed if the pennil is Tor one I TOTAL Y❑ NC:] Y❑ N❑ Z) 2 hundred dollar,1$100)or less U O I certify that in the performance of me work for which this Per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL U nit is issued.I sical not employ any person in any manner so as to becomgs b'cct yo he Workers'Compensation Laws of California. BUILDING O w Dale)/YI�IQ.�!Spplicant e, L ER OR ADD TO MECH. 4.00 } rail NONCE TO .SIIPLICANT: If,after making this Certificate of fix- H Z emption,you should became 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 ibis permit shall be deenmd revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00 CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE (JV I hereby affinn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 the performance n We work for which this ermit is issucJ(Sec. MICROFILM 3097.Civ.C.1. �� HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lender's Name IsHEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC nti </Qnr o^ 5�--/21/I = I oertiAddress cfy (h:nl bout read this upplicmion vad stale tint the above VENTILATION FAN (SINGLE) 3.00 information is correct. I agree to comply with all city and county PLUMBING ordinances and state laws relating m building construction, and BOILER-OOMP(3 H.P.or 100,0006.T.U.) 4.00 hereby authorize representatives 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, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against Iiabilities,judgmenu, cost and expenses which CONST.TAX may in any an accrue Coy s: conque of PERMIT ISSUANCE 3.00 gran o permit. } MECH.CONT. LIC.NO. MECH. � a he TOTAL TOTAL k9igmtool of Applicant/ lommiltor Da 4F� OFFICECOPY