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3379 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -' USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION C BER -BUILDING APPLICATION & PERMIT.,,= 3379' Av BUILDING - ELECTRICAL-PLUMBING,-MECHANICAL OWNE.. ^•L rr - PLAN CHECK VALIDATION' NAME /� - L4UDIS. PIIONE�(+c^� I•31 DTV. ELECTRIC PERMIT FEE - ONTRACTORS ';. NAME _WAOUTLETS-SWITCHES-RECEP 5.00/1.00 No. LIGHTING FIXTURES 5.00/1.00 -. - CONTRACTORS- - - APPLIANCES-RESIDENTIAL 4.00. ADDRESS PHONE PANELS 5.00 DATE OF APPLICATION ARCHITECT © SIGNS' - ;6.00 ENOIN PLAN CHECK FEE OR - EER LIC.No. 0 SIGNS TRANS. 3.00 ' ARCH.OR ENG. i PERMIT VALIDATION AOORESS C/ SPECIALCIRCUIT 5,00 - • - - ZIP Q rTEMP.METER OR POLE INS. 15.00 - (� APPLICANTSMOTORS, -PAI®E FEE SCH. ADDRESS L SERVICE CHANGE - "10.00 0 00 oo LICIiNSEDCONTRACTORS DECLARATION; U I Q U I hereby affirm that I am licensed tinder provisions of Chapter 9 4 ( " ISSUANCE DATE v,¢ N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. K w z Professions Code,and my license is in full force and effec6.; I of Cupertino E� ❑ Z,i In W License Class Lie Number ❑ Dl- ! � , Date Contractor BUILDING PERMIT Ix w OWNER-B611-DER DECLARATION INFORMATION wO A r I hereby affirm that I am exempt front the Contractor's License - MISC.- - REFER TO ORD 3 u y VALUATION $/FT. H I.D¢ Law far the following reason.(Sec.7031.5,business Professions ,PERMIT ISSUANCE, 6.00 Code:Any city or county which requires a permit to construct,alter, •� Q p a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ILIFou requires the applicant for such permit to file a'signed statement that TOTAL � PERMIT TO v wm m he is licensed pursuant to the provisions of the Contractor's License as Law(Chapter 9(commencingwith Section 7000)o(Division3ofthe ' ¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE M = $ the basis for the alleged exemplipn.Any violation of Suction 7031.5 STORIES TYPE CONSTR. og by any applicant for a permit subjects the applicant oacivil Penalty gLTER-DRAIN -WATER IEA.) 4.00 of n t more than five hundred dollars(S5001J: 3 - ryis I,as owner of life property,or my employees with wages as O BACK FLOW PROTECT.DEVICE 2.00 DCC.GROUP, RES.UNITS tReir de compensation,will do the work,and the structure is not - - intended or,offered for sale'(Sec. 7044. Business and Professions O DRAINS-FLOOR,ROOF,AREA,COND. 4.00' - Cade:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work 149 FIXTURES-PER TRAP 4,00 0.^ a0.FT,FLOOR AREA TOTAL ACREAGE , bimpch'or through his awn employees,provided that such innprovo GAS-EA.SVSTEM-11NC.40UTLETS 4.00 Oa C Js arerov notintendld proffered for sale.If,however,the building f- der will have is sob within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) . 1.00 BUILDING USE prove of will have the boolale,), 'of proving that he did not build or im- RES , IND CON Pa Omer prove for,Owner of shop 0 INDUSTRIAL WASTE INTER. "20.00 ❑ d c owner of the properly,am rHjectvely.7044contracting with - - - ❑ ❑' ❑ ❑ . ❑' licensed contractors m construct the Pricense La.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 - ASSESSORS PARCEL NO. and n owner of Code: ty Contractor's License Law re snot apply to an owner of property who huilAs or improves thereon;and who p LAWN SPRINKLERS-OVER 5 (EA.). 1.00 contracts for such projects with is co straciods)licensed pursuant to - theContramor'sLicenseLaw. SEWER-SANITAR V-ST . 200ft/9.00 ,TRACT Not PARCEL NO. ❑ I:un exempt under Sea. ,B.&P.C.or hiis WATER HEATER W/VENT 4,00 00 reason Date -41'1-2- 1 15']- - Owner _ WATER SYSTEM 4.00 Aec.DATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION 0 WATER TREATING EQUIP. 4.00 1 hereby atfirm that I have a certificate of consent to sell-insure, uty of ZONING ENG.SITE NO. a or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sea.3800,Lab.C.). - Policy No. Can.paiTy , O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24 Z Z ❑ Certified copy is filed with the city inspection division. . : MISC.- REFER TO ORD. O Applicant - �,� V❑ N❑ v ❑ N❑ CC 'CERTIEICATI'OP EXEMPTION PROM WORKERS' PERMIT ISSUANCE . - _ 6.00 ( FLOOD ZONE A.L.0 C. LU COMPBNSATION INSURANCE PLG.CONTR. LIC.NO, 4 PLG. ..J O 0` - ❑ ❑ ❑ ❑ d O (This-section ned enot be completed.if the permit is tit,one TOTAL O y .N Y N Z hundreddollars(8100)o,less:) i U O ' I certify that in the limforrience of the work 1'o,which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY LL U mit is issued,I shall nut employ any Person in anymanner so as to O hecbme subject to the Workers'Compensation Laws of Calltontia. c.w nam Applicant / ALTER OR'ADD TO MECH. 4,00 BUILDING } 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex- - " F•Z emplion,YOU should become subject to the Worker:Compensal ion APPLIANCE /I/ 4.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE ' V- such provisions or this permit shall be destined revoked. AIR HANDLING UNIT(TO 1 ,ODOO F.M.1 3.00 CONSTRUCTION LENDING AGENCY O AIRHANDLINGUNIV 10MC.F.M.) 5.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WUCT) 2.00 00 the performance of-the work for which this permit Is issued(Sec. kLX-R - MICROFILM 3097,Civ CA HEATING UNIT(T 100;0 .T.U.) 4.00 _ Lender's Name Lender's'AJdrcss ELECTRIC I C HEATING UNIT VER 100,000 T.U.)7.50 I certify that l have read this application and Itad"'Ul liteabove Q VENTILATION FAN ISINGLE)'_ 3.00 ���" Ir pnnar on is correct. I agree'ro comply with all city enA county PLUMBING 1 qs and stale laws relating tO building construction,wb U BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 J!", athon, repnttntatoes of Hus city to enter up nn the d BOILER-COMP'(Over 100,000 B; SEE FEE SCH. MECHANICAL . mens'('a properly fon;Inspection purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. -- CupertUm against liabilities,judgments, cases and expenses which - CONST.TAX may in nny wry accrue against said City in consequence of the PERMIT ISSUANCE _ 3.00 • ,anti, of Ihis permit. MECH,CONT. : LIC.NO.-' MECH. 4.�(_]_�83 TOTAL TOTAL �2 Signature of pplicmll/Contractor Date 'OFFICE COPY '