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12481APPLICANT TO FILL IN INFORMATION: WITH IN RED LINES - USE BALL POINT PEN ONLY ILDIING PROJECT IDENTIFICATION APPLICATION &PERMITDDRES BUILDING — ELECTRICAL— PLUMBING — MECHANICAL PERMIT NUMBER 124 81 AIL ISG ILUIN D Ii0—I?_J �� NIRS NAME V72,ry� 1 QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION ly-s-G HONE _ DATE OF APPLICATION CONTRACTORS I 1ry- GLI1:.No,v:Z",k,38LIGHTINp-FIXTURES UTLETS-SWITCHES-RECEP 10.00/1.00 10.00/1.00 rorvTRACTOR'S oREss y.S 1 1 G PHONE S_• APPLIANCES - RESIDENTIAL 4.00 PANELS 10.00 ARCHITECT LIc. No. PANELS (OVER MO AMP) 20,00 PLAN CHECK FEE P.C. NO, SIGNS TRANS. 3,00 RAPPLICANT SPECIALCIRCUITS,OO PERMIT VALIDATION EMP. METER OR POLE INS. 20.00 ADDRESS MOTORS • SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSU NCE DATE (commencing with Section 7000) of Division 3 of the Busi-n Professions Cod , amb ty license Is in full force Liccn' as O Liu Number_ BLDG. ELECT. El PLG. MECH. ❑ Date Ce / BUILDING PERMIT OWNER-BUILDTION I hereby affirm that I am e CoNractor's License Law for the following reaso.(Ssiness and Professions Code: Any city or county Mich req uirce a permitto construct alter, improve, demolish, or re r 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 Contractors License INFORMATION MISC. — REFER TO ORD VALUATION PERMIT ISSUANCE 10.00 ELEC. CONTR. LIC. NO. ELEC. TOTAL p PERMIT TO QTY. PLUMBING PERMIT FEE Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 / L STORIES TYPE CONSTR. gLTER-DRAIN-WATER IEA.) 5.00 by any applicant for a permit subjects the applicant ton civil penally of not more than five hundred dollars ($5001.): ❑ I, as owner of the property, or my employees with wages as their Sole compensation, will do the work, and the structure is not intended or offered for sale (See 7044, Business and limfessinns Z BACK FLOW PROTECT, DEVICE 4.00 ,U . GRUP OCCO RES. UNITS DRAINS -FLOOR, ROOF, AREA, CON D. 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 E'C FIXTURES - PER TRAP 5.00 (3 sO. IT, FLOOR AREA TOTAL ACREAGE himself or through his own employees, provided that such improve- mems are not intended or offered for sale. It, however, the building GAS 6.00 ' �y u0 or improvement is sold within one year of completion, the owner builder will have (lie. e burden of proving that he did not build or im- prove for purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with GAS - EASYSTEM -OVER 4 IEA.) 2.00 BUILDING USE RES IND CON PR Omer ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE I- 30.00 LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ILAWN SPRINKLVARI'5ffff 1.00 ASSESSORS PARCEL NO. licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of properly who builds or improves thereon, and who contracts for such projects with a contractods) licensed pursuant to the Contractor's License Law. TRACT NO. PARCEL NO. SEWER -SANITARY -STORM EA. 200ft/10.00 ,U ❑ 1 am exempt under Sec., BAP.C. for this reason WATER HEATER Mftinjj 6.00 ACC.DATE ACC, FILE No. ,Owner Date 1 WATER SYSTEM 5.00 S:CO WATER TREATING EQUIP. 5.00 WORK F-RS'COMPENSATION DGCI.ARATION 1 hereby affirm that 1 have u Certificate of Consent to self -insure. Or a certificate of Workers Compensation Ins a CC'rtltied copy thee��gqtf 1�$$qqc 00, Lab.C.) Policy N __IJTL om y r ` ❑ Certified cap er f s s ZONING ENG, SITE NO. FIRESPRINK ENERGY T 24 O C Ill city inspection Ivision. APP icant MISC. - REFER TO ORD. y NO Y 1 N❑ C' TIFI TEOF EXF PTION PROM WORKERS' PERMIT ISSUANCE 10.00 JU4V FLOOD ZONE A.L.U.C. PLc. CONTR. LIC. NO. PLG. ,I55'7f�� TOTAL�sOD COMPIiNS ION INSURANCE IT Sec n need nal be ompletcd if the permit is for one ban cd dollars($ 100) or less.) I certify that in the performance of the work for which this per- mit is issued, I shall not employ any person in any manner so as to Y ❑ N ❑ Y ❑ N❑ OTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of -California. Dale Applicant x - NOTICE TO APPLICANT: If, after making this Certificate o(E ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 PLAN CHECK emptim" you should become subject to the Workers''Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FEE AIR HANDLING UNIT ITO 10MC.F.NL) 4.00 AIR HANDLING UNIT (OVER I000C.F.M.) 6.00 SEISMIC FEE . CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work r which this permit isissued(Sec. 3097, Civ.C.). 1� EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATING UNIT 100,000 B.T.U.)9.50 ELECTRIC Lender's Name Lender's Addmss 1 certify that I have read this application and Ste a that a above information is correct. I agree to comply with all city and county ordinances and state laws relating to building Construction, and VENTILATION FAN (SINGLE) 4.00 PLUMBING 3� BOILER-COMP13 H.P. or 100,000 B.T.U.1 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. MISC. - REFER TO ORD. CONST. TAX (We) agree to save, indemnify an armless the City of Cupertino against liabiliti juJs, s and expenses which may in any a I in c n quence of the tin of r(/ PERMIT ISSUANCE 10.00 MECH. CONT. LIC. NO. MECH. .. TOTAL TOTAL Si tare of plicant/Contract Date OFFICE COPY