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10018APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION &PERMIT BUILDING -ELECTRICAL- PLUMBING -MECHANICAL PERMITNUMBER 10018 BW LOING A, DRESS , I it �� ^/ OW ER N A#PLAN Nam /`( QTY- ELECTRIC PERMIT FEE CHECK VALIDATION L!['� PRONE CONTRACT R3 ry E UTLETS-SWITCHES-RECEP 10.00/1.00 /�z LIc. ND. LIGHTING FIXTURES 10.00/1.00 DATE OF APPLICATION CONTRACTOR'S / /i7AODPE 7 �(f /E lr`"PRONES/ PPLIANCES- RESIDENTIAL 4.00 PANELS 10,00 ORRLXITECT ENGINEER uc. NO. - PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 noo ESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP EMP. METER OR POLE INS. 20.00 PaD APPLICANT a ADDRESSoREss MOTORS SEE FEE SCH. fE1 y g NOV SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my, license is in full force a f c!. License Class 7�.Lic. Number % BLDG. E MECH. ❑ ❑ ❑ Date bContmctor l�.�tiYalJktT OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, _ BUILDING ERMIT INFOR ATION MISC. - REFER TO ORD PERMIT ISSUANCE 10.00 VALUATION S/FT. ELEC. CONTE. LIC. NO. ELEC. TOTAL improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License PERMIT TO Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE 1 el STO ES YPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): ALTER -DRAIN -WATER IEA.) 5.00 ❑ 1, as owner of the property, or my employees with wages as sole compensation, will do the work, and the stmetum is not BACKFLOW PROTECT. DEVICE 4.00 Oce. DRouP RES. UNITS DRAINS -FLOOR, ROOF, AREA,COND. 5.00 intended or Offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of ' FIXTURES - PER TRAP 5.00 Q GAS - EA. SYSTEM - I INC. 4 OUTLETS 6.00 50. Fr. FLOOR AREA TOTALACREAGE property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- ments are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or im- prove for purpose of sale.). D 1, as owner of the property, am exclusively contracting with GAS EASYSTEM -OVER 4 IEA) 200 • . .. - BUIL SE IND PB Other ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 licensed contractors to construct the project (Sec. 7044, Business 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- 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ssEsco BP RGEL No. contracts for such projects with a contmctos(s) licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑ I am exempt under Sec. ,B.&P.C. for this reason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE N0. WATER TREATING EQUIP. 5.00 WORKERS'COMPENSATION DECLARATION 1 herehy affirm that 1 have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy thereof (Sec. 3800, Lab .C.I / Policy No. Company Ft"09, krp FIRE SPRINK Y ❑ N❑ ENERGY T-24 Y.❑ N❑ ❑ Certified copy,is he I furnished. A)}�Q Certified s B wi v city inspection division. p$i an[ MISC- REFER TO ORD. CERT . TP F@%IiM N OM WORKERS' PERMIT ISSUANCE 10.00 /0146 FLOODZONE A.L.U.C. COM ENSATION INSURANCE This section need not be completed if the permit is for one PLG. CONTR. LIC. NO. PLD. TOTAL Y❑ IN C] Y❑ N hundred dollars ($100) or less.) I certify that in the performance of lire work for which this per- mit is issued, I shall not employ any person in any manner so as to OTY. MECHANICAL PERMIT FEE I FEE SUM ARV BUILDING - become subject to the Workers' Compensation Laws of California. Date Applicant ALTER OR ADD TO MECH. 5.00 NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption, you should become subject to the Workers' Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you most forthwith comply with such provisions or this permit shall be deemed revoked , FEE AIR HANDLING UNIT (TO 10=C.F.M.) 4.00 AIRHANDLING UNIT(OVER 10PMC.EM.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 per 3097, performance of the work for which this permit is issued (Sec. the MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 6.00 HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC Lender's Name Lender's Address I certify tja l have read this application and stale that the above information is correct. I agree to comply with all city and county it ordinances and state laws relating to building comw Ilion, and VENTILATION FAN (SINGLE) 4,00 PLUMBING - BOILER-COMP(3 H. P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL ./hereby authorize rcpresenmtives of this city to enter upon the above-mentioned property for inspection purposes. MISC. - REFER TO ORD. CONST. TAX , (We) agree to sxv , ndert ify and keep harmless the City of Cupertino aga' I' i ties dgments, costs and expenses which may in an wa ce artist said City in consequence of the PERMIT ISSUANCE. 10.00 grantln lh' / MECH. CONT. LIC. NO. MECH. TOTAL TOTAL SignhalFJK licant/C Tactor Date f1` I - OFFICE COPY