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10865APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER BUILDING Ao Ells BUILDING - ELECTRICAL- PLUMBING - MECHANICAL 10865 GAINER'6 PLAN CHECK VALIDATION AME TY. ELECTRIC PERMIT FEE PXDNE DATE OF APPLICATION CONTRACTOR'S NAMEOUTLETS hi LIC. No. ff -SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 CONTRACTOR'S ADOREss Try PPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 ARCHITECT OR ENGINEER uc. No. PANELS(OVER 200 AMP) 20.00 PLAN CHECK FEE P.0. NO. P 01 in ISIGNS TRANS. 3.00 ARCH, OR ADDRESS ENG SPECIALCIRCUIT 5.00 P _DATION TEMP. METER OR POLE INS. 20.00 21p FEB h �� APPucANT's ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 MY of �I1 MY Pertino LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code it M nY IS In (UII for ! P LicenY C - Lic. Number _ ISSUANCE DATE BLDG. ELECT. I ❑ ❑ PLG. MECH ❑ Dale Contractor BUILDING PERMIT INFORMATION OWNER -BUILDER DECLARATION I hereby clthat I so exempt from me Contractor's License Lawfor the following m-own.(Seauires a,ermit to endtrofaslons Code: Any city or county which structure, a permit to is Esunrc ,also ecdoe,the applicant repairany hpar-ructofileu Signor its also he is lac she applicant for such revisit to Ilk ir signed statement that he is licensed pursuant to the provisions of the License MISC.- REFER TO ORD PERMIT ISSUANCE 10.00 VALUATION $/FT. ELEC. CONTR. LIG NO. ELEC. TOTAL p IT TO DTV. PLUMBING PERMIT FEE )ofDiyision Division 30l the Law (Charter 9 (commencing with Section is exempt Business and Professions or That he is exempt therefrom and STORIES TYPE CONBTR, the basis for the alleged exemption. Any violation otoaction crops malty by any applicant fore permitsubjects $500R.licmv nracivil penalty of not more than Five dollars (my ALTER-DRAIN-WATER(EA.)5.00 em): ❑ 1, as owner at the property, or my employees with wages as the prop sole compensation, will the work, and Clic structuress not BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AR EA,CON D. 5.00 intended or offered for sale (See. 7(doe Business and ince far (S owner os n Code: The Contractor's License Law does not apply to an owner of work who builds his son em s thereon, and whoadoes t such improve- himself ownemrloyees,ke.provided however, the imildin menti are not intendcJ or offered for sak. If, however, the building Rents fre sof intended FIXTURES -PER TRAP 5.00 so. Fr. FLOOR AREA TOTAL ACREAGE GAS-EA.SYSTEM-I 6.00 or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or ins_ prove for purpose of Sale.). ❑ I, as owner of the property, am exclusively contracting with GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 BUILDING USE REs IND CON PB Omer ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 licensed contractors to construct the project (Sec. 7044, Business 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 - 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. LAWN SPRINKLERS - OVER 5 (EA.) 1.00 Contracts for such projects with a contractotts) licensed pursuant to the Contractors License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑ lam exempt under Sec... B.&P.C. for this reason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC.DATE ACC. FILE NO. WORK F-RS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate of consent to Ylf-intim, ilicase of Coo or a .crtWorkers' Compensation Insurance, r a certified ZONING ENG. SITE NO. copy tl e - f�' 38pp, Lab.C.;) \ Policy SSS ii'nv party ❑ e rtlfied copy is hereby furnished. f�Cenif to IIr�L.jvith the city inspection division. Arhficant 1 Q. FIRE SPRINK Y ❑ N❑ ENERGY T -2I Y ❑ N❑ MISC. - REFER TO ORD. CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. PLG. CONTR. LIC. NO. PLG. TOTAL COMPENSATION INSURANCE. (This section need not be completed if the permit is for one Y ❑ N ❑ Y ❑ N ❑ hundred dollars IS 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 CITY MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of California. [)ate Applicant ALTER OR ADD TO MECH. 5.00 NOl'ICE TO APPLICANT: If, after making this Certificate of fix. emption, you should become subject to the Workers' Compensation provisions of the labor Code, you must forthwith comply with such provisions or this pennit shall be deemed revoked. APPLIANCE 5.00 PLAN CHECK FEE AIR HANDLING UNIT (TO 10)000GF.M.) 4.00 AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.D0 the performance of the work for which this permit is issue] (Sec. 3097, CP.CJ, MICROFILM HEATING UNIT ITO 100,000 B.T.U.) 8.00 Lender's Name Lenders Aadress HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC I versify that l have read this,ppliwtiun and state that the above VENTILATION FAN (SINGLE) 4.00 - information R correct. I agree to comply with all city and county ordinances and state laws eating to building construction, and PLUMBING BOILER -COMP (3 H.P. or 1 D0,D00 B.T.U.) 6.00 BOILER -COMP 1 Cor 100,000 BTU) SEE FEE SCH. MECHANICAL hereby authuri a representatives of this city to enter upon the above-mentioned property for inspection Purposes, (We) agree to save, indemnify and keep hamdcss the City of MISC. - RE R TO, RD. Cupertino against liabilities, judg Its, cost and exrensrs which may i any way accrue vgai t id City m consequence of the oti of this permh. CONST. TAX , PER T ISSUANCE .00 e- M H. CONT. LIC. NO. t H. ^ TOTA O� Sv TOTAL IgnaluY of Apphcaot/Contractor Date OFFICE COPY