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10180 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER BUILDING ,y AooRESs 10180 018 0 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1 OWNER'S PLAN CHECK VALIDATION NAME PRONE OTY.. ELECTRIC PERMIT FEE I (�mnryy g - risme /si�lrp$ �a�,�I UTLETS-SWITCHES-RECEP 10.00/1.00 d ¢.No. 36 LIGHTING FIXTURES 10.00/1.00 -DNTRAGTOR's as PPLIANCES-RESIDENTIAL 4.00 ADORE PHom PANELS 10.00 DATE OF APPLICATION RRCNITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. O ENGINEER LIC.NO, SIGNS TRANS. 3.00 ADDRRESS ENc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION T S ZIP EMP.METER OR POLE INS. 20.00 ADDRESSTs 1 MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 ac w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 < i W I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE a y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. F h z Professions Code and my license is in full to d if m o 0 m- License C ss •+ Lia NumberVt ��•/3-Yr s r a ❑ ❑ ❑ F W H j Con Date tracr to 31 1 5 X w a OWNER-BUILDER DECLARATION BUILDING PERMIT -"0 e. u INFORMATION X a, o I- 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD w m VALUATION LL O a Law for the following reason.(Sec.7031.5,Businemand Professions - PERMIT ISSUANCE 10.00 y i Code:Any city or county which requires a permit to construct,alter, M ar a Q improve,de1110I1511,or repair any alrllC[Ilre,prlOr!O IIS ISSDanCe,d150 ELEC.CONTR. LIQ NO. ELEC. to LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO A w 9 m he is licensed pursuant to the.provisions of the Contractor's License H i> Law(Chapter 9(comm¢nciagwith Section 7000)of Division 3 ofthe C F o Business and Professions Code)or that he is exempt therefrom and OT PLUMBING PERMIT FEE X I- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES. TYPE CONSTR. a;_ by any applicant fora permit subjectsthe$500h.licaN toacivilpenalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars(my em): ❑ 1,as owner at the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS their sole compensation,Sale (o the work,and the structure is not intended or offered for sale se L 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 L_ SG.FT.FLOOR AREA TOTAL ACREAGE �r himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 ments are not intended or offered for sale.If,however,the building or improvement is sold within one year of Completion,the owner. 7 - builder will have the burden of proving that he did not build or m_ GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE prove for purpose of sale.). INDUSTRIAL WASTEI 30.00 RES IND CON PB Omer ❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 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 SPRINKLER E 5'IE t' 1.00 contracts for such projects with a contractons)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACTNO, PARCEL NO. ❑ lam exempt under Sec..,B.&P.C.for this WATER HEATER W/ Bp .00 reasonTAV Owner Date WATER SYSTEM 5.00 ACC.GATE 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 ZONING Compensation Insurance,or a certified ENG.SITE NO. copy thereof(Sec.3800,Lab.C.).�� O .w� e 71. I Policy No. Company�2 Z�` ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY TI4 Fes• ❑ Certifie o y is filed ilh Ile city 'Ispey coon division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑ Applicant .V cit rwccr,��T V N V N CC T Ch:RTI FICATE OF EX17MPTION FROM WORK Ii RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. W L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. y❑ N❑ v ❑ N❑ LU Z (This section need not be completed if the,permit is for one TOTAL hundred dollars IS 100)or Iesy) U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F mil is issued,I shall not employ any person in any nsenner so as m U become subject to the Workers'Compensation Laws of California. 0 y Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING } W NOTICE TO APPLICANT: If,after making this Certificate of Ex-- ? coalition,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 he deemed revoked AIR HANDLING UNIT TO 10=C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 the C 309 .ec .)performance of the work for which this permit is issued(Sec., HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 Lender's Address ELECTRIC Icertify that l haveread this application amialme dual the above VENTILATION FAN (SINGLE) 4.00 information is correct. I agree to comply with all city and county PLUMBING ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the BOILER-COMP (over 100,000 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 PERMIT ISSUANCE 10.00 CONST.TAX may in any way accrue against said City in consequence of the gamin 0 [hisp mil �Z - MECH.CONT. LIC.NO. MECH. TOTAL TOTAL Signatureof Ap nl/Contractor ate OFFICE COPY