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13688
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER aNILDInG APPLICATION & PERMIT ° ©Bq�� 107_913688 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL OYan ER'SPLAN CHECK VALIDATION NP �E� ) i 41,,5' �i QTY. ELECTRIC PERMIT FEE (.\/ SSDL. PHONE 41-:5S0 COEIPaCTORS C/D / UTLETS-SWITCHES-RECEP 10.00/1.00 /S rvA E CuQP / L uc.No. (� L53 LIGHTING FIXTURES 10.00/1.00 CONTRACTOR'STd 1, PPLIANCES-RESIDENTIAL 4.00 PO55 2:5, ] y ORE2 G 2 J J PHONE - /53 PANELS 10.00 DATE OF APPLICATION OR ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.No. ENGINEER Llc.NO. SIGNS TRANS. 3.00 ADDRESS Enc' SPECIAL CIRCUIT S,QQ PERMIT VALIDATION ZIP TEMP. METER OR POLE INS. 20.00 APPLICANTS MOTORS SEE FEE SCH. ADDRESS �(' L SERVICE CHANGE 20.00 I6 (r'' I� f�V(/`"l�r ` 000 VLSI. UUU L � I� � F o a LICENSED CONTRACTORS DECLARATION a i w 1 hereby affirm that I em licensed under provisions of Chapter 9 I 1 <'1ISSUAN ATE N a w (commencing with Section 7000)of Divisiony�3�aof�f the(Hputsiness DailJ LI .BLDG.% EL CT LG. MECH. r H z Professions Codc,a ease u in full fo"r(OLS3 z O sn - License Cle Lie.Number 2 Y Lhim_� Conlructor M a OWNER-BUILDER DECLARATION B G. IN�S/PE I IUII BUILDING PERMIT w D CI11 0 !`119 ',INFORMATION w n w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD LLOa Law for the following reason.(Sec.7031.5,Business and P,.I.,ons pERMIT ISSUANCE 1000 0-- improve, / VALUATION f/FT. � - Cade:Any city or county which requiresa permit tocmutruCL alter, rt ¢< o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. - DLL requires the applicant for such permit to File a signed statement that TOTAL P IT TO n w he is licensed pursuant to the provisions of the Contractor's License I H zr Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. n , by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00 of not mom than five hundred dollars($500).): ❑ 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 Profcudmis 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 SD FT.FLOOR ARCA TOTALACREAGE homer or through his own employees,provided that such improve- Trials am at intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.40UTLETS 6.00 r or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE builder will have the burden of pmving that he did not build or im- Prove for purpouofSale.). INDUSTRIAL WASTE INTER. 3000 RES IND .CON PR Omer ❑ I,as owner of the properly,an)exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Code:The Contractor's 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 contractorts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft110.00 the Cra tmcloi s License Law. TRACT NO, PARCEL NO. ❑ I am 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. WORK VRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby atfjrm that I have o car Ija1e u2cpnscyt O a ertil'i ZONING ENG.SITE NO. orco" aycTiRiBf4l somil. fkcr/K'O(nle if n '1 0011 or a ccrlified Policy tfiNo. �T �f jCjoomLpaabnnyy,YC?V4J2 htA O ❑ CarFficdcopyishcmbyfurmsheJ. FIRE SPRINK ENERGY T-24 Z Z _,0-Certified copy is Filed with the city inspection division. O Applicant_ ; Misc.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑ fLT CERTIFICATE 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 C. W >_ COMPENSATION INSURANCE PLG.CONTE. LIC.N0. PLG. Y El ❑ Y ❑ N❑ CL o (This section need not be completed if the permit is for one TOTAL ::) Z hundred dollars(5100)orless.) U O I certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY LL 1- mit is issued,1 shall not employ any person in any manner so as 10 U become Subject to[be Workers Compensation laws of Califomia. 0.WDate Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } rn NOTICE TO APPLICANT: If,after making this Certificate of Ex- Z 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 1Q0000F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p000EM) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 the performance of the work to,which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM 3097,Civ.C.). Lender's Name Lender's Add, HEATING NIT(OVER 100,000 B.T.U.) ELECTRIC ess U / 7 1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 information is correct. I agree to consply 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 mpresematives of this city to enter upon the BOILER-COMP (0ver 100,000 BTU)SEE FEE SCH. MECHANICAL abme-mentioned properly for inspection purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX may in any way accrue against said City in consequence of the enlingof his 1. MECH,CONT, LIG NO. MECH. �S TOTAL TOTAL GCI' Si a[ � fApplicam/Contractor Ulc OFFICE COPY