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09758 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LOI NG PROJECT I DENTI FICATI ON I PERMIT NUMBER ao'ILDIN f ,ttc� ( (� APPLICATION & PERMIT �nS3.J Sr !S�'( 4. BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 09758 OWNER'S NAMEce* PLAN CHECK VALIDATION •� iv OTV. ELECTRIC PERMIT FEE T� uAITL1K �,PcP PHONE 4W' \ NOMERAcroRs .,rP UTLETS-SWITCHES-RECEP 10.00/1.00 /\ (�I.11 Lt..No. D LIGHTING FIXTURES 10:00/1.00 CONTRACTOR'S _ ) �� xx[[�r[[ APPLIANCES-RESIDENTIAL 4.00 p-µ PHONE PANELS 10.00 DATE OF APPLICATION RRCHIrscr PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE .C.NO. O ENGINEER Llc.NO. SIGNS TRANS. 3,00 ADDRESS END' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 APPLICANT'S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 ��/gy (�� woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 Y/7 v I�C a i w I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE H (commencing with Section 7000)of Division 3 of the Business and < BLDG. ELECT. PLG. MECH. H m i Professions Co e-a d my license is in full for u e fec� ❑ El, ❑ ❑ 0 m License lass Z Lic.Number. O Uate Contractor < m s BUILDING PERMIT ¢o i OWNER-BUILDER DECLARATION INF ON m ;LL I- 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD a, .. Din Law forthe following reason. 7031.5,Business and Professions PERMIT ISSUANCE VALUATI N S/FT. Code:Anycityorcounty which requires a permit to construct,alter, 10.00 CaU Qa Q Q Improve,demolish.or repair any structure,prior 10 Its Issuance.also ELEC.CONTE. LIC.NO. ELEC. /O o¢ requires the applicant for such permit to file a signed statement that TOTAL ER TO w $ he is licensed pursuant to the provisions of the Contractor's License 'yy HiQ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe e J U i i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE H$ the basis for the alleged exemption.Any violation of Section 7031.5 STORI S T PE CONSTR. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00 of not more than five hundred dollars(S500)J: ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS their 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. 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 sO.FT.FLOOR AREA TOTALACREAGE himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 6.00 mems are not intended Or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE builder will have the burden of proving that he did not build or im- RES IND CON PB Other prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ I,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 SPRINKLERS-OVER 5(EA.) 1.00 contracts forsuch projectswilh a contractors)licensed Pursuant to SEWER-SANITAR V-STORM EA.200fU10.00 theContracloisLicenseLaw. TRACT NO. PARCEL NO. ❑ I um exempt under Sec. ,B.A.P.C.for this WATER HEATER W/VENT 6.00 reason . . Owner - Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate ofcnnsent to sel Ginsure' ZONING ENG.SITE N0. or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24 Z Cl Certified copy is Filed with the city inspection division. MISC.- REFER TO ORD. Applicant Y ❑ N❑ V ❑ N❑ Cr H CERTIFICATE:OF Ii XEMPT10N FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.D. W > - CC)41:NSATI01,1 INSURANCE: PLG.CONTR. LIC.NO. PLG. CL Z (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑ hundred dollars(S 100)or IussJ - U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL I. mil Is Issued,I shall not employ any person in any manner so as to O W becom 'u It �p lire Workers qpm a inion ws of California. 4 Dute1 E T YS Applicant sy7V ALTER OR ADD TO MECH. 5.00 BUILDING �d- } In NOTICE: TU APPLICANT: If,otic laking this Certificate of Ex- F Z emption,you should became subjec to the Worker'Compensation APPLIANCE 5.00 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 10,000C.F.K) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10,0000.F.M.16.00 SEISMIC FEE 1 hereby affirm that there is a construction lending agency for I EXHAUST HOOD(WITH DUCT) 5.00 the performance of the work for which this permit is issued(Sec. MICROFILM 3097,Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 6.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 Lender's Address ELECTRIC I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 information is correct.I agree to comply with all city and county PLUMBING I ordinances and state laws relating to building construction, mud BOILER-OOMP(3 H.P.Dr 100,000B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the BOILER-COMP toyer 100,000 BTUI SEE FEE SCH. MECHANICAL above-mentioned property for inspection purposes. (We) agree 10 save, indemnify and keep harmless the City of Misc.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which CONST.TAX may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 gra 'ogoflhi permit MECH.CONT. LIC,NO. MECH. TOTAL TOTAL Signature Applicant/Contractor Date OFFICE COPY