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11809_ �_��± /:� � -:«� � »�� ,� �Z \� \� / ; � � \� \� � � k ~ °� � � � �� »� � �� .� � � c . � k \#� «�\2A � 2 >-« �`��,�� . - A& � \� 4� : � e � _ lI PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN'ONLY O Z_Z N it LU T - CL 0 Z UO U. Ow } N U qb BUILDING PROJECT I DENTIFICATION APPLICATION & PERMIT - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 11809 BUILDING ADDRESS bF)BUILDING OWNER'S NAME ,-�Gj3 J�� 1 L A/Y L ✓ PHONE QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION CONTRACTOR'S NAME �' I.f\ OUTLETS -SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 DATE OF APPLICATION CAq C DR' DOREs_ ADDRESs s ZaL-C- �� • 131r ` P PPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 ARCHITECTPANELS OR ENGINEER LIC. NO. (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C. NO. ,, SIGNS TRANS. 3.00 ' ARCH. OR ENO.SPECIAL ADDRESS ' zip CIRCUIT 5.00 PERMIT VALIDATION r. Q 2 r�r _ TEMP. METER OR POLE INS. 20.00 APPLICANT'S ADDRESS ' MOTORS SEE FEE SCH. SERVICE CHANGE 20.00°i}Pf�^ 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 andBLDG. Professions Code, it s 'cense is in full force and f ct. Cass Lic. Number ISSUANCE DATE El ELECT. PLG. MEC ElLicense Dale Contractor ' BUILDING PERMIT OWNER -BUILDER DECLARATION 1 hereby affirm that I so exempt from the Contractor's License Professions Law for the following reason(Sec.uires Business to Code: Any city or coo my which requires permit to Consuanc ohm, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed actor's i that he is licensed pursuant the provisions of the License INFORMATION MISC.- REFER TO ORD VALUATION S/FT. ' PERMIT ISSUANCE 10.00 ELEC. CONTE. LIC. NO. ELEC. TOTAL PERMIT TO QTY. PLUMBING PERMIT FEE Division3 of the en )ofDivision Law (Chapter 9(commencing with Section is exempt Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 SIE TYPE CONSTR. ALTER -DRAIN -WATER IEA.) 5,00 by any applicant for a permit subjects the applicant to a civil penally of not more than five hundred dollars ($500).): ❑ 1, 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 (Sec. 7044, Business and Professions BACK FLOW PROTECT. DEVICE 4.00 DRAINS -FLOOR, ROOF, AREA,COND. 5.00 OCC. GROUP RES. UNITS Code: The Contractor's License Law does not apply to an owner of property Who builds or improves thereon, and who does such work FIXTURES - PER TRAP 5.00 SD, FT. FLOOR AREA TOTALACREAGE improve - himself or through his own employees, provided that such atimprove- mems are not intended or offered for sale. If, however, the building GAS - EA. SYSTEM -1INC. 4OUTLETS 6.00 or improvement is sold within one year of completion, the owner builder will have the burden of proving that h e did not build or am-- prove for purpose of sale.). ❑ 1, as owner of file property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who . GAS - EASYSTEM -OVER 4 (EA.) 2.00 BUILDING USE RES IND CON PB Omer ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. contracts for such projects with a contractods) licensed pursuant to the Cc ntraclors License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. WATER HEATER W/VENT 6.00 Cl I am exempt under See.-, R&P.C. for this reason Owner Dam WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00 1 hereby affirm that I have a certificate ofc.nsCnt to lel Ginsure, or a certificate of Workers' Compensation Insurance, or a Certified ZONING ENG. SITE NO. copy lhereof(Sec. 3800 Lab.CJ. Policy NU73Wany 01� ClnYwn lt•l. ❑ Certified copy is hereby furnished. Certifie�, Wpy��d Aith then ity 'n1pNc rt division. Applicant 111 1 p Fl FIRE SPRINK YEJ___❑, No, ENERGY T-24 y N❑ MISC.- REFER TO ORD. CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.LO.C. PLG. CONTE. LIC. NO. PLG. TOTAL COMPENSATION INSURANCE (This section need not be completed if the permit is for one Y ❑ N❑ Y ❑ N❑ DTV. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars IS 100) or less.) I certify 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 BUILDING became subject to the Workers' Compensation Laws of California. Date Applicant- NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption,.you should become subject to the Workers Compensation provisions of the Labor Code, you must forthwith comply Witt' such provisions or this permit shall be deemed revoked. ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 PLAN CHECK FEE AIR HANDLING UNIT (TO 10,000GF.M.) 4.00 AIRHANDLING UNIT(OVER 10AWC.EM.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097. Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATING UNIT(OV ER 100,000 B.T.U.) 9.50 ELECTRIC Lender's Name Lender's Address VENTILATION FAN (SINGLE) 4.00 PLUMBING 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 slate laws relating to building construction, and BOILER- COMO(3 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000BTU) SEE FEESCH. MECHANICAL / hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. _ Misc.- REFER TO ORD. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any Way accrue against said City in Conseil ace of the CONST. TAX PERMIT ISSUANCE 10.00 ME H. CONT. LIC. NO. MECH. ' 1 1I TOTAL/P.p V(1"t\1I TOTAL r' I gof this perm:. I S lure of Applicant/Contac or al OFFICE COPY