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14037 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDING PROJECT I DENTI FICATION UILAPERMIT NUMBER BDING APPLICATION & PERMIT J, ooPE95 14037O�S SSM/LL..�aC X v�, BUILDING-ELECTRICAL-PLUMBING-MECHANICAL OWNER'S y; d - PLAN CHECK VALIDATION NAMET��/ .1- 1 CITiV,.• ELECTRIC PERMIT FEE PHONE CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00 NANT`Al %T7i LIC.No, LIGHTING FIXTURES 10.0011.00 CONTRACTOR TOP'S /)_ /-,m) - PPLIANCES-RESIDENTIAL 4.00 17'5PRONE PANELS 10.00 DATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. OR ENGINEER uc,No. SIGNS TRANS. 3.00 ARCH.OR ENG. -PERMIT VALIDATION ADDRESS _ SPECIAL CIRCUIT 5.00 - ZIP EMP.METER OR POLE INS. 20.00 ~ n APPLICANT a MOTORS - SEE FEE SCH. ADDRESS - SERVICE CHANGE A 20.00 lO97 woo.00 LICENSED CONTRACTORS DECLARATION • < v u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCEDATE 0 (commencing with Section 7000)of Division 3 of the Business and F BLDG ELECT.` PLG. MECH. is '^ Professions Code,and my license is in full fort a f sy` 2 o m- License Cln Lie.Number .] / / 0 ❑ ❑ O z-I- Date / y��Contractor ��Ct� y�- i.- Y s ^,/ ! _ BUILDING PERMIT IF W< OWNER-BUILDER DECLARATION INFORMATION oA" MISC. REFER TO ORD E: ; s• I hereby affirm that 1 am exempt from the Contractor's License - o Law for the following reason.(See.7031.5,Business and Professions PERMIT ISSUANCE 10.00 vnwnnoN $/FT. LL m Code:Any city orcounty which requires permit to construct,niter, a to improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. a O u it requires the applicant for such permto file a signed statement that TOTAL PERMIT TO a$m he is licensed pursuant to the provisions of the Contractor's License �z> Law(Chapter 9(commencing with Section 7000)of Division 3 of the f 4 c Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE re I—$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. a ; by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00 of not more than five hundred dollars($500).): Cl I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES'.UNITS their sole compensation,will do the work,and the 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 does not apply to an owner of property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 ,SO.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- mentsarenot intended oroffered for sale.IL however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 or improvement is sold within one year of completion, the owner GAS-EASYSTEM-OVER 4(EA) 200 BUILDING USE builder will have the burden of proving that he did not build or im- . . . RES IND CON PB Omer prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 AWESSORSPARCEL NO. and Professions Code:The Contractors 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/10.00 TRACT NO. PARCEL NO. the Co ❑ I am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO. or a certificate of Workers'Compe cation Insurance,or a certified copy thereof(;cc.3800,Lab.C.).�/� V U - Policy No. Company O O Crfi Dad Cop Is hereby farm t 1.' FIRE SPRINK ENERGY T-24 Certif Is til wl he city nspection division. MISC.- REFER TO ORD. Z z0 Appl°�n� .ti v ❑ N❑ Y ❑ N❑ ri PERMIT ISSUANCE 10.00 - CERTIFICA'l E OF EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C. -W > COMPENSATION INSURANCE PLG.CONTR. uc.rvD. PLG. CL D (This section need'not Abe completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑ Z) Z hundred dollars IS 100)or less.) U O 1 certify that in the performance of the work for which this per' CITY. MECHANICAL PERMIT FEE FEE SUMMARY LL F- mit is issued,I shall not employ any person in any manner so as to U become subject to the Workers'Compensation Laws of California. O y Dnm Applicant ALTER OR ADD TO MECH. 5.00 BUILDING >_ W NOTICE TO APPLICANT: IG after making this Certificate of Ex- ? 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 10,000C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE I hereby af6rn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 the performance of the work for which this permit is issued(Sec. MICROFILM 3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 6,00 Lender's Name Lender's Address HEATING UNIT(OV ER 100,000 B.T.U.)8.50 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 PLUMBING ordinances and state laws relating to building construction, and BOILER-COMP(3 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. MECHANICAL above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which CONST.TAX may in any way accrue,against said City in consequet ce of the PERMIT ISSUANCE 10.00 granting�of�Sys craft. `� MECH.CONT, LIC.NO. MECH. /!L TOTAL / /�- TOTAL ♦sill `I t Signature of Applicant/Contractor Date OFFICE COPY