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C 8287 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUI Lbfl NG PROJECT I D TI FICALICATION & PER PERMI NUMBER -P . BUIL ENG /� ADDRESS 1� 8287'/ 0 7 ld 99-i©a�3 Nr l� 1�i�ti2 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL f8 G OWNERY ^Q��WQ •T.0µV(,� PLAN CHECK VALIDATION NAME L+vr QTY. ELECTRIC PERMIT FEE PHONE cTORs NAME UTLETS-SWITCHES-RECEP 10.00/1.00 NAME ADDRESS LIC.NO. LIGHTING FIXTURES 10.00/1.00 AGToms APPLIANCES-RESIDENTIAL 4.00 OORES PHONE PANELS 10,00 DATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 20.00 PLANCHECK FEE P.C.NO. OR ENGINEER f//'' ' ..N., /�7dtif SIGNS TRANS. 3.00 ARCH OR ENG,'a-W S_ I SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ADDRESS O��VO 6/(-E_ ZI1, ,$-•� EMP.METER OR POLE INS. 20.00 APPLICANTS13 O S 0 In' MOTORS SEE FEE SCH. ADD,_)s yel III CAL. gsO&'w SERVICE CHANGE 20.00 �� o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 <v U I hereby affirm that I am licensed under previsions of Chapter 9 SUANCEOAT (commencing with Section 7000)of Division 3 of the Business and D ELECT. PLG. MECH. ry i Professions Code.and my license is in full force and effect. r ❑ El o i Lit m o License Class ' .Number Date Contractor E .�, BUILDING PERMIT ce ,m a OWNER-BUILDER DECLARATION INFORMATION o A O REFER TO ORD E g N I hereby affirm that I am exempt from the Contractor's License MISC.- u o a Law for the following reason.(Sec.7031.5,Bu,sinessund Professions PERMIT ISSUANCE 10.00 ���/`/jfffAL�UATION S/FT. H - N J Code:Any city or county which requires permit toe...o rucLalteq /f/1 -71 FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ,�LN/ rr 0 E, requires the applicant for such permit to file a signed statement(bat TOTAL PERMIT TO n w m the is licensed Pursuant to the provisions of the Contractors License F z t Law(Chapter9(commencing with Section 7000)of Division 3 ofthe < Business and Professions Code)or that he isexempl therefrom andQTY. PLUMBING PERMIT FEE the basis for the alleged exemption.Any violation of Section 7031.5 STORIES PE tONSTR. dF_ by any applicant for,permit subjects the applicant tea civil penalty ALTER-DRAIN -WATER IEA.) 5.00 of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT-DEVICE 4.00 OCC.GROUP RU.UNITS their sole compensation,will do the work.and the structure is not (J/¢/ intended or offered far side tS,e. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's License Law does nut apply to am owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 56 FL FLOOR AREA TOTAL ACREAGE • himself'or through his own employees,provided chit such improve- ments are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00 i'1 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE builder will have the burden of proving that he did mol build or ire- E IND CON PB - Omer Pr v;,for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 j( I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ frmsed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Code:The Contractor's License Law dues not apply to an owner of property who builds or improves thereon.and who ILAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 tic Contractors License Law. TRACT NO. PARCEL NO. ❑ I.mexcm funder Sec. .B.&P.C.tmthis WATER HEATER W/VENT ' 6.00 reason if =N owner ) t WATER SYSTEM 5.00 ACC. E f PCC.FILE N0. WORK BRS'COMPENSA'EION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that 1 have a certificate of consent to self-insure, ZONING or d certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO, copy thereof(Sec 3800,Iab.C.). Policy No. Company O ❑ Certified ropy is hereby furnished. FIRE SPRINK ENERGY T 24 Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. p Applicant Y ❑ N❑ Y ❑ N y CERTIFICATE:OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U,C. LU > COMPF;NSA7'ION INSURANCE: PLO.CONTH. LIC.NO. PLG. d 0 This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ No Z hundred dollars IS 1001 or less.) U O I certify that in the performance of the work for which this per, DTV MECHANICAL PERMIT FEE FEE SUMMARY 1- iLls issued,I shall net employ any person in any manner so as to LL U ' 4nc subject to the Workers'Compensation Laws of Calitornia, a D Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } Ua ICE TO APPLICANT: If,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 1Q000QF.M-) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6,00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 the performance of�{m work for which this,,j'ermil is issued(SEC. MICROFILM 3097,CN.C.). �ANy o Nrhee,,f- 4- HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address � /�fHEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC i -'�'g.3L� 1 � I certify that I have read this applicatimh and state that tiro above VENTILATION FAN (SINGLE) 4.00 • information is correct. I agree to comply with all city and county PLUMBING mdorances 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,judgruents, costs and expenses hick CONST.TAX may i any way accrue aga' t said C' cense nee d the PERMIT ISSUANCE 10.00 Ul 'n oI t rm1� MECH.CONT. LIC.NO. MECH. O IBI fen -APpTOTAL TOTAL che Eric .O ^• OFFICE COPY i Z N z- y rnJ w �a ro CM F .y N tT d]3 °° L o I*— f-J to r d t 3� n m a W IL a' 'r ry w� ...1 U p lL N Z C. a J aF x c wo , V O 7 a O d Z N ¢ V t/f 0 4J a W al w V w F- C W W W m _ tz ZF V ^ Yd J 1 J d J O LL > dF y o > a > a > a ¢ > N w o Ivl p L ¢ ~ > F ¢ > F ¢ > wa w r ¢ 1 a 0 $ CJ f OW OI 01 L) Z 1yl Z> p>t LL p L J 4 mN J �m n cic. 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