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09872 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY A BUI DI Nb PROJECT IDENTI FIC I / - PERMIT NUMBER ADDRESS APPLICATION & PER_ T 09872 ADDRESS © L' A BUILDING -ELECTRICAL-PLUMBING-MECHANICAL OWNER'S - PLAN CHECK VALIDATION !� NAME DTV. ELECTRIC PERMIT FEE PHONE 6. HOMIER c*oRs UTLETSF I-SWITCHES-RECEP 10.00/1.00 �YFa�IL BVCV 011 LIC.... 1I 0 IU7 LIGHTI NG XTUR ES 10.00/1.00 ONTR_ ADORRess'oR's APPLIANCES-RESIDENTIAL 4.00 DY PHONE PANELS 10.00 DATE OF APPLICATION ON ARCHITECT ,. - PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO. ENGINEER L. No. SIGNS TRANS. 3.00 ADDRESS s SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 APPLI EMOTORS SEE FEE SCH. ADDRESS SERVICE CHANGE 20.00 / / p- '.09 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 (/'�/ a ii u 1 hereby affirm that I am licensed under provisions of Chapter 9 195UANCE DATE N Q y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. L, O'z Professions Code red my license is in full I'o .a"I f z O - License Class Lic.Number 1 8 -O Dam _ =Contractors wa OWNER-BUILDER DECLARATIO BUILDING T IT - INFORMATION w ; u� I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD u0. Law for the following reason.(Sec.703 t.5,Business and Professions VALUATION $/FT. � - Code:Any city orcounty which requires a permit to construct,alter, PERMIT ISSUANCE 10.00 2 ¢ ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. n O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO e w m he is licensed pursuant to the provisions of the Contractor's License riaLaw(Chapter 9(commencing with Section 7000)of Division 3 ofthe 4 O Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE M 'V w r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. e 3 - by any applicant for a permit subjects the applicant to a civil penalty ofnol more than five hundred dollam($S00).): ALTER-DRAIN&VENT-WATER (EA.) 5.00 O I,as owner of the property,or my employees with wages as BACK FLOW PROTECTDEVICE 400 their sole compensation,will do the work,and the structure . . structure is not OCC.GROUP RES.UNITS intended u,offined 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 docs such work FIXTURES,PER TRAP 5,00 SQ FT.FLOOR AREA TOTAL ACREAGE • himself or through his own employees,provided that such improve- ments are not intended or offered for sale.If,however.the huilding GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 Or improvement is sold within one year of completion,the Owner- GAS-EA.SYSTEM OVER 4(EA.) 2.00 builder will have the burden of proving that he did not build or iin- BUILDING USE prove for purpose of sale.). RES IND CON Pe Orhe1 ❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 licensed contractors to construct the project(Sec. 7044,BusinessLAWN SPRINKLERS-1 IN 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 IEA.) 1.00 contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM /10.00the Contract.,s License Law. TRACT NO. PARCEL NO. ❑ lam exempt under Sec..,Is&P.C.tar this WATER HEATER N 6.00 reason Owner Date WgTER SV STEM (t\\\ 5.00 ACG DATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING 5.00 1 hereby affirm that I have a certificate of consent to self-insure, or a certificate of Workers'Compensation Insurance,or a Certified ZONING ENG.SITE NO. copy thereof f$ec.3800,Lab.C.)'� Policy ere 0m b. fret-1-6'1/rJs..i O ❑ Certified co y s hereby fur 'shed. FIRE SPRINK ENERGY P2g Z ❑ Certified C is fed v t the city 'n. - n division. MISC. REFER TO ORD. YE]Applicant - ❑ N[D y [] No D: O CERTIFI ATE OP F:%IiA1PTl0 ROM WORKERS' PERMIT ISSUANCE 10,0070 FLOODZONE A.L.U.C. LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. _q TtlV r N r N� CL Z (This section need'not be completed if the permit is for one TOTAL Rte hundred dollars($100)or less.) U O I certify that in the perl'Ormunce of Dte work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY U_ U mil is issued, I shall not employ any person in any manner so as to O W become subject to Dte Workers'Compensation Laws of Californin. d Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } to NOTICE TO APPLICANT: If,after making this Certilicate of Ex Z emption,you should became 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 10DIXIC.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 tho 3097 eCiv C Once of the work for which This permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM Lender's NameHEATING UNIT(OVER 100,000 B.T.U.)9.50 Lender's ess ELECTRIC I certify That I have read this application and slate That Ile above VENTILATION FAN (SINGLE) 4,00 information is correct.I agree to comply with all city and county PLUMBING ordinances and stale 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 r above-mentioned property for inspection purposes. (We) agree In save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and.expenses which pEfl MIT ISSUANCE 10.00 CONST.TAX may in ly way accrue uinst said City in consequence f t e Orrin f this ermiL MECH.CONT, LIC.NO. MECH. OTAL TOTAL ig t re of Applicant/Conlmctor Dat OFFICE COPY