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12319 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT ' ADDRESS S O BUILDING— ELECTRICAL—PLUMBING'—MECHANICAL 12319 OWNER'S ,/ PLAN CHECK VALIDATION NAME , / n QTY. ELECTRIC PERMIT FEE 1(� r PHONE 9a9 < CONTRACTOR NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 N IQFIrxID.�LL/Nb .No. LIGHTING FIXTURES 10.00/1.00 CONTRACTOR'S CRmPs`V APPLIANCES-RESIDENTIAL 4.00 AooREss ,6 a HDrvE 3 d7d6 PANELS 10.00 DATE OF APPLICATION ORRcerecT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO. ENGINEER ' LIC.No. SIGNS TRANS. 3.00 ADDRRESS ENC' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 APPLICANTS MOTORS SEE FEE SCH. v/( ADDRESS SERVICE CHANGE 20.00 .Pnfi Woo LICENSED CONI RACTORS DECLARATION l y3�I Q b iw I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE m a N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. H D z Professions Code,a my license is in full force a Idle( c �. Z, i=W License Class Lie.Number Z w H Data -2— O — Contractor a x s BUILDING PERMIT ¢ ¢ ¢ OWNER-BUILDER DIiC ARATIOR S,a 0 INFORMATION ee a-y I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD u0¢ Code:Any following reason.Ih e.703 requires a permit to construct. Professions Law VALUATION $/FT. � - 0 � Code:Any city or county which rcquiresa permit to<onstrucLalteq PERMIT ISSUANCE 10.00 2 rt Q 2Improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. F. D¢ requires the applicant for such permit to file a signed statement that TOT Cs u PERMITTO � a he is licensed pursuant to the provisions of the Contractor's License PE HiQ Law(Chapter9(commencing with Section 7000)of Division 3 of the E i 0 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢ H m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00 of not more than five hundred dollars(5500).1: ❑ I,as owner of the properly,or my employees with wages as ggCK.F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.LINOS their sale compensation,will do the work,and lire structure is not intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's License Law docs not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50,FT.FLOOR AREA TOTAL ACREAGE himselfor through his own employees,provided that such improve- ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 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 im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE Prove 1,as owner of stheJ' RES INDUSTRIAL WASTE INTER. 30.00 ❑ I❑ ❑N ❑ ❑ Rua ❑ d as owner of the property,am exclusively contracting with licensed contractors m construct Ore project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 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 contractors)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STO OOft/10.00 TRACT NO. PARCEL NO. ❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATERW/VE .00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO. WORKERS'COMPENSATION DECLARATION WgTER TREATING SRI I hereby Alum that 1 have a certificate of consent to self-imnre. or a certificate of Workers'Compensation Insurance,or a certified mb, ZONING ENG.SITE NO. copy thercof(Sec.3800,Lab.C.). - Policy No. Company ' O ❑ Certified copy is hereby furnished. RE SPRINK ENERGY T-T4 FO Appli Z Z ❑ Certified tiled r Byy inspection division. cant n MISC.- REFER TO ORD. Y [D NE] Y [3 NE] CCT CERNFICA ' F EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00116 FLOOD ZONE A.L.U.C. LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Q' (This section need not be completed if the permit is for one TOTAL /�— Y N� Y ❑ IN Z hundred dollars IS 100)or les) U O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL H mit is issued,I shall not employ any person in any manner so as to O become subject to the Workers'Compensation Laws of California. a Date Applicant BUILDING } W NOTICE TO APPLICANT: If,after making this Cerificam of rix- ALTER OR ADDTO MECH. 5.00 F ? 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 10=C.F.INL) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 the perform.nee of the work for which this permit is issued(Sec. 3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM Lender's Name Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC ® I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and BOILER-COMPLUMBING H.P.or 100,000 B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. above-mentioned property for inspection purposes. MECHANICAL (We) agrto save, indemnify and keep harmless the City of MISC.- REFER TO ORD. ee Cupertino against liabilities,judgments, costs and expenses which CONST.TAX may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 grantingoft sperm(. MECH.CONT LIC O. MECH. A Signatureol icant/Contractor Ua[e t -� TO TOTAL /n OFFICE COP i�a�a� e�� , . - � �, �, �°r�� oe'�-�o ,�� ,� . . ' �' � �•