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12017 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER APPLICATION & PERMIT BUILDING a OORE$5 \1 C�'- ��. BUILDING -ELECTRICAL-PLUMBING -MECHANICAL 1201 OWNER'S PLAN CHECK VALIDATION N& Me)(_ R,� (> PHONE DTV. ELECTRIC PERMIT FEE � '�Illr/1 CONTRACTOR'S -N�(LE�I '/r ��--'� / ��Q OUTLETS-SWITCHES-RECEP 10.00/1.00 - T V'-UV C LF:: -1 m.14047M6L I LIGHTING FIXTURES 10,00/1.00 ADDREacTOR's APPLIANCES-RESIDENTIAL 4.00 A PHONE` l0 o& PANELS 10.00.),1 DATE OF APPLICATION AARRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. ENG IN EEO uc.NO SIGNS TRANS. - 3.00 ADDRREOR SS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 ,A , ADDRESS is MOTORS SEE FEE SCH. APPLICA SERVICE CHANGE s' 20.00 �d / F o o LICENSED CONTRACTORS DECLARATION Q U w 1 hereby affirm that 1 am licensed under provisions of Chapter 9 C 5 ISSUANCE DATE w a (commencing with Section 7000)of Division 3 of t e um rex and BLDG. ELECT. PLG. MECH. F D i Professions Cnds ulreacense is in full for d s!T Liz ❑ ❑ Z i D Licenu Class CC.-.. VV Lac.Numb Q. ll..__ I 1 t El. SCI m H Dale_j/S� A_7/ Contract,, fry BUILDING PERMIT ¢ ¢ w OWNER-BUILDER DECLARATION INFORMATION E ;a I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD aoa Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION E/FT. fw>9 Code:Any city or county which requires a permit to construct,alter, D improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0, ELEC. K p LL requires the applicant for such permit t0 file n signed statement that TOTAL PERMIT TO he is licensed pursuant to the provisions of the Contractor's License a F z Q Law.(Chapter 9(commencing with Section 7000)of Division 3 ofthe �GLTL7 4 D Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE ¢ H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. by any applicant(or a permit subjects the applicant toacivilpenalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 of not more than five hundred dollars(5500).): ❑ 1,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 50.FT.FLOOR AREA TOTALACREAGE himself or through his own employees,provided that such improve- mentsarenotintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 or amprovement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 builder will have the burden of proving that he did not build or im- BUILDING USE prove for purpose of Sale.). RES IND CON PB Other ❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ D ❑ 1:1 ID 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 Contractors License Law docs not apply to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 , contracts for such projects with a contractors)licensed pursuant to )SEWER-SANITARY-STORM EA.200ftI10.00 the Contractor's License Law. TRACT NO. PARCEL NO. ❑ Iwn exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO, WORKERS'COMPENSATION DFCLARAT ION WATER TREATING EQUIP. 5.00 I hereby affirm that I have 'ertillcat"AI ofconsentioself-insure, or a certificate of Workers' on ensation Insurance,or a certified ZONING ENG.SITE NO. copy thereof(Se 3grB, ,b.0 Policy No. spiry ❑ Certified copy' hereb ( abed. FIRE SPRINK ENERGY T24 Z Z Cl Certified col f d lh the inspection division. MISC.- REFER TO ORD. O Applicant Y C] N❑ V ❑ N[] CC CERTIF 'A .OFE _ ION PROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C. L 7 MP: TION INSURANCE. PLG.CONTR. LIC.NO. PLG. Z (This section need not be completed if the permit is for one TOTAL Y N� V N� hundred dollars IS 100)or less.) U O I certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued,I shall not employ any person in any mummer so as to 0 Ed U become subject to(lie Worked Compensation Laws of Cafiromaa. IL Datc Applicant ALTER OR ADD TO MECH. 5,00 BUILDING - )- rya NOTICF.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 must forthwith comply with - FEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10P=WCF.M.) 4.00 CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE I hereby affirm that Diere is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 the performance of the work for which this permit is issued(Sec. MICROFILM 3097,Cu.CJ. , HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 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 ordinances and state laws relating to buildg construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 6.00 hereby authorize representatives of this to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-me4t. sav forms clam poses. (We) dem an ep harmless the City of MISC.- REFER TO ORD. Cupertino gm costs and expenses which PERMIT ISSUANCE 1000 CONST.TAX may in asins City in consequence of thegumting0MECH.CONT. LIC.NO. MECH. 1ora _ TOTAL TOTAL Signatu la Conlr tar Date - OFFICE COPY