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3434 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT.PEN ONLY BU I LDING PROJECT I DENTIFICATI ONPERMrgIrBe 0ORGING /J/ /.) APPLICATION & PERMIT /� 3 /1 RE s - X ADO `F LF BUILDING ELECTRICAL-PLUMBING-MECHANICAL O N 'a PLAN CHECK VALIDATION NAME TY. ELECTRIC PERMIT FEE 11 /e/ PHONE ;FFV-Of IV Ilk CONTRACTORS - rvnMEP n / /�,r " � .5 g��/ OUTLETS-SWITCHES-flECEP '.5.00/1.00 X 1 "0'40" A-9J0A LIC'ND 1 63`17 LIGHTING FIXTURES 5.00/1.00 CONTRACTOR OR's APPLIANCES-RESIDENTIAL 4.00 �Q/�Jpr P/f'A/O R�7�NFHONE _-" PANELS 5.00 GATE OF APPLICATION ARRCHITECT - SIGNS 6.00 PLAN CHECK FEE P.C.NO. ENGINEER - uc.No. SIGNS TRANS. 3.00 ADDRESS ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP EMP.METER OR POLE INS. 15.00 ADDRESS AMOTORS SEE FEE SCH. P '� ADDRESS SERVICE CHANGE 10.00 1� p,163U w O o LICENSED CONTRACTORS DECLARATION ¢ v I hereby affirm that I am licensed under provisions of Chapterr9 _ ISSUAN OATE. y<n (commencing with Section 7000)of Division 3 of the Business and BLDG. yyyE MECH. • r o z Professions Co and y license is in full fort•' a elt. {--1 ❑ ❑ License Class Lin.Contract., "0 u o m r w Oate Contractor ¢ , s BUILDING PERMIT a aew u OWNER-BUILDER DECLARATION INFORMATION - X ;e I- I hereby affirm that I am exempt from the Contractor's License' MISC.- REFER TO ORD u o a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 VALUATION $/FT. Code:Any city or county which requiresapermit to construct,alter, Q5 < improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC. / O , requires the applicant for such permit to file a Signed statement that TOTAL q PERMITTO w$ he is licensed pursuant to the provisions of the Contractor's License FiQ Law(Chapter 9(commencing with Section 7000)of Division 3 of the f i o Business and Professions Code)or that the is exempt therefrom and CITY. PLUMBING PERMIT FEE ¢ 1-$ the basis for the alleged exemption.Any violation of Section 70315 STORIES TYPE CONSTR. u ; - by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).) ALTER-DRAIN&VENT-WATER.(EA.) 4.00 �0yP Uyr, ❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.CHOU RES.UNITS their sole compensation,will do the work,and the structure is not intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SG.FT.FLOOR AREA TOTAL ACREAGE himself re through his own employees,provided that such improve- ments are not ll,mutended or cm,loyee,,ffered for pre.ovided IlmeL the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4,00 or improvement is sold within one year of completion,the owner P. GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE builder will have the burden Of proving that he did not build or in)- RES IND CON PB Omer prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 O I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. ,and Professions Code:The Contractor's License Law does 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 contractor(s)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO. ❑ lam exempt under Sec. ,B.&I'.C.for Ibis. - WATER HEATER W/VENT 4.00 reason Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 1 hereby affirm that 1 have a certificate of Consent to selRinsure: ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified 'Copy thereof(S",3800,Lab.C.). Policy No. Company Q ❑ Certified copy is hereby furnished. ' FIRE SPRINK ENERGY T 24 Z Certified copy is filed with.Jhe city inspection division. MISC. REFER TO ORD. ZO LICertified Y❑ N❑ Y ❑ N❑ ' ~ w LU CERTIFICATE EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C. W _ COMPENSATION INSURANCE PLG.CONTR. u0.NO. PLG. IL O ('this section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑ D 2 hundred dollars($100)or less.) U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY LL mit is issued,I shall not employ any person,in any manner so as to 7Q becmn��yy b��'e��-t to the Workers'C9.yl pereation Laws of Calilbrnis. BUILDING y Date-7J/ Appl. cant gZZ,ot v •. �^� ALTER OR ADD TO MECH. 4.00 } N NOTICCff TO APPLICANT: If,after making thbrCertiticato of Ex- F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 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 10,f100C.F.M.) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE 3U I hereby affirm that-there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 the performance of the work for which this permit is issued(Sec. MICROFILM 3097,Cv GA HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lender's Name Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC 1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 . .' information n correct. I agree to comply with all city and county PLUMBING ordinances and state laws relating to building construction, andmy BOILER-COMP(3 H.P.or 100,0008.T.U.) 4.00 hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property for inspection purposes. I - (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 3.00 CONST.TA may in any way accrue against said City in consequence of the It tin f this permit. MECH.CONT. LIC.NO. MECH. TDT"` TOTAL 0 °% S lure o pplica Contractor Da - OFFICE COPY