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9212APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL - PERMIT NUMBER 9 212 I BUILDING ADORES V owNER'a � [-,VQTY �, L Nqe �k"uf PHONE ELECTRIC PERMIT FEE PLAN CHECK VALIDATION DATE OF APPLICATION 1 namencTORs - . sec. NO. UTLETS-SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 C,ONTRACTOR'S A REss C '(•fS • ©• J J r PHONE ��O „'� APPLIANCES - RESIDENTIAL 4.00 PANELS 10.00 ARCHITECT OR ENGINEER LIC. No. PANELS (OVER 200 AMP) 20.00 I PLAN CHECK 7 P.C. NO. ISIGNS TRANS. 3.00 ARCH OR ADDRESS ENG. ZIP SPECIAL CIRCUIT 5.00 Pryr VALIDATION �1 JUL j�Cs 185 /s City Of$C gpertiDnt�E EMP. METER OR POLE INS. 20.00 ADDRl ssTS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION 1 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 fore • a { f Lic rn las Lic. Number fS.�G[dr� Date j' Cootracrm:wi�gt(/l� OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following ressom(See 7031.5, Business and Professions Code: Anycityorcounty which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement thatTOTAL he is licensed pursuant to the provisions of the Contractor's License Law (Cbapler 9 (commencing with Section 7000) of Division 3 ofthe Business and Professions Code) or that he is exempt therefrom and Orebasis for the alleged exemption. Any violation of Section 703 LS fora permit subjects the 0).): and lou civil penalty by any more of not marc than five hundred dollars (my em : ❑ I, as owner at 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 (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of Propertywha builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- mentsarenolintendedOrofferedforsale. 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,;m_ prove for pulp.. of sale.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to Construct the project (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a conlractort licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec. , B.&P.C. for this reason TEMP. POLE 30.00 - BLDG. ❑ E E P EC . BUILDING ERMIT INFORMATION MISC. - REFER TO ORD PERMIT ISSUANCE 10.00 _ VALUATION $/FT. ELEC. CONTE. LIC. NO. ELEG PERMIT O / QTY. PLUMBING PERMIT FEE ALTER -DRAIN VENT -WATER IEA.) 5.00 STORIES' VP ONSTR. BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES. UNITS DRAINS -FLOOR, ROOF, AR EA, COND. 5.00 FIXTURES - PER TRAP S.OD GAS- EA.SYSTEM-1 INC.4 OUTLETS 6.00 17 GAS - EA. SYSTEM -OVER 4 IEA.) 2.00 SQ FT. FLOOR AREA TOTAL ACREAGE BUILDING USE RES IND CON Pa Other INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. LAWN SPRINKLERS - OVER 5 (EA.1 1.00 SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. WATER HEATER W/VENT 6.00 Owner Dat, WATER SYSTEM 5.00 WORKERS'COh1PENSAT10N DECLARATION 1 hereby affirm that I have a certificate of consent to o lFinsure. or a certificate of Workers' Compensation Insurance, or a certified I copy there O Lah.C.1. e Policy No. ..puny_ ❑ C, i cop whereby felon bed 13Ce L is fd,J 1 'nspectian division. Arid ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 ZONINGENG. SITE NO. MISC.- REFER TO ORD. FIRE SPRINK V N ENERGY T" 24 v N� C IiRTI F 1 CATE O F Ii X E M PTION F ROM WO R K 1: RS' COMPENSATION INSURANCE (This section need not be completed if the permit is for ane hundred dollar, IS 100) or less ) I cerlity that in the performance of the work for which this per. mil is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of Calit'ornia. Dale Applicant No r1Cli "TO APPLICANT: If, after making this Certificate of Ex - emption, you should become subject trr the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall he deemed revoked CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the perlormance of the work for which this permit is issued (Sac. 3097, Civ.CTL Lender's Name Lender's Address I certify that I have read this application and stale that the above information is correct, I agree to comply with all city and County ordinances and state laws relating to building C ... ructiom, and hereby authorize representatives of this city to enter upon 1h, above-mentioned property for inspection purposes. (We) agree to save, indemnify. and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in ay 'true agai s send C' nsequ®me of the grant Oft mit. PERMIT ISSUANCE 10.00 FLOOD ZONE Y [DN [:]V A. L.U.C. N PLG.CONTR. LIC. NO. PLG. TOTAL QTY MECHANICAL PERMIT FEE FEE SUMMARY BUILDING ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 AIR HANDLING UNIT (TO 10=1 ,F.M.) 4.00 PLAN CHECK FEE AIR HANDLING UNIT(OVER 10=C.P.M.)6.00 SEISMIC FEE EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM ELECTRIC HEATING UNIT (TO 100,000 B.T-U.) 8.00 HEATI NG UNIT (OVER 100, 000 B.T.U.)9.50 VENTILATION FAN (SINGLE) 4"00 BOILER- COMPH.P. or 100,000 B.T.U.) 6.00 PLUMBING(3 / 801 LER-COMP 100,000 BTU) SEE FEE SCH. MECHANICAL ✓✓ MISC. - REFER TO ORD. PERMIT ISSUANCE 10.00 CONST. TAX MECH. CONT. LIC. NO, 2 G/� 7-/�-J q MECH. TOTAL / ��• TOTAL e Signature. ApplicamContractor Date urrit.0 COPY