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1769 (kPPLICANT TO FILL IN INFORMATION WITHIN RED LINES --USE BALL POINT PEN ONLY BU LD1 NG PROJECT I DENTI FICATION PERMIT NUMBER _ _ _ 1769 ADDRESS APPLICATION & PERMIT OGRESS � BUILDING—ELECTRICAL—PLUMBING —MECHANICAL PLAN CHECK VALIDATION NAME �T DTV. ELECTRIC PERMIT FEE . BeJGsE /�.CIT - 'HONE CONTRACTOR'S NAME- OUTLETS•SWITCHES-RECEP 5.00/1.00 uC No. LIGHTING FIXTURES 5.00/1.00 ADDRESS TOR's APPLIANCES-RESIDENTIAL 4.00 PHONE. PANELS_ 5.00 DATE OF APPLICATION ARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO. ENGINEER uc.No. SIGNS TRANS. 3.00 - ADDRREss ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 15.00 • Ars ADDRESS _ MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 '09 LICENSED CONTRACTORS DECLARATION rt v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE ammennn with Section 7000)of Division 3 of the business end a,a m (e g BLDG. ELECT. PLG. MECH. r.o z Professions Co and my license is in full fo f Eat' Z 02 LILennC 1 ss Lie.Number DNDate •� Contmetor H ¢ yea OWNER-BUILDER DIiCLARATlO V O� BUILDING PERMIT ¢ v �� . INFORMATION wca ;'LL y 1 hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD J - Law forthe following reason.(Sec,7031.5,Business and Professions PERMIT ISSUANCE 6.00 /v�ALUATIpN E/FT. Code:Any city or county which requires a permit to construct,alter, ai7.q. 2 C ¢ 0 improve,demolish,or repair any structure,prior to its issuance,Nso ELEC.CONTE. LIC.NO. ELEC. wvV a ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO K $,y he Is licensed pursuant to the provisions of the Contractor's License / HZ > Law(Chapter 9(commencing with Section 7000)of Division 3 of the 4 4 o Business and Professions Code)or that he is exempt Iherefroot unit QTY. PLUMBING PERMIT FEE the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. e , by any applicant lore permit subjects theapplicvuton civil penalty ��• of not more than five hundred dollars the .1: ALTER-DRAIN& VENT-WATER (EA.) 4.00 ❑ I,as owner of the property,or my employees with wagesas BACK FLOW PROTECT. DEVICE 2.00 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. 4.00 / Code:'fine Contractor's License Law docs not apply to an owner of property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SQ FT.FLOOR AREA TOTAL ACREAGE himself re through his own employe",fors le.If,ho that such ments not intended orofferedforsalc.Iided that such building GAS-EA.SYSTEM-1INC.4OUTLETS 4.00 ^. or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA) 100 BUILDING USE builder will have the burden of proving that h . . . e did not build or im- RES D CON PB Omer prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20,00 ❑ [,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 Cade:The Contractor's License Law does mol apply P—40 co builds an owner of property who ballon r improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 Q_/Q contracts for such projects with a contractpn s)licensed pursuant to thetam rn eLicense Law. SEWER-SANITARY-STORM EA.200ft/5.00 TRACT NO, br reason ❑ tarn exempt under B. Sec. , &I'.C.for this l' WATER HEATER W/VENT 4,00 �L 1910 DateOwner WATER SYSTEM 4.00 ACC.DA E ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 ^ I hereby affirm that 1 have a certificate of consent to scl Ginsure' SITE NO.ZONING ENG.S or a certificate of Workers'Compenratlon Insurance, ma certified _ copy thereof(Sec,3800,La b.C.). Policy No. Company 'If'[�r_-!(.r!_� ^ , O ❑ Certified co a II��rr by forms FIRE SPRINK ENERGY T 24 Z ❑ Certified o Ste A city inspection division, MISC.- REFER TO ORD. �y Applicant �� 'ILi ~ o PERMIT ISSUANCE 6.00 CIi RTIPICATF 'XIiM PTION FROM WORKERS' FLOOD ZONE �CRr¢L W COXI . SATION INSURANCE PLG.CONTE. LIC.No. PLG. C Z (This section recd not he completed if line permit In for one TOTAL Y❑ d"Q J hundred dollars(SI00)or less.) U 0 I 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 O U become subject to the Workers'Compensation Laws of California. 6d Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING /Q } NOTICE TO APPLICANT: If,after making this Certificate of Ex- F _ Petition,you should become subject to[lie Workers'Compensation APPLIANCE 4.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with - ,FEE U such provisions or this permit duall he deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00 CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 5.00 SEISMIC FEE 1 hereby affirm that there is a construction lending agency for EXHAUST HOOD)WITH DUCT) 2.00 the performance of the work for which this Be rn.it is issued(Sec. MICROFILM 3097,Civ.C.L � H EATING UN IT(TO 100,000 B.T.U.) 4.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 Lender's Adore ELECTRIC ,l certify that l havernad this application and state that the above VENTILATION FAN (SINGLE) 3.00 information is correct I u8ree to comply with all city and counlY PLUMBING ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 4.00 hereby authorize representatives of this city to'enter upon chi above-mentioned Property for inspection purposes. BOILERCOMPIOver 100,000 BTU)BEE FEE SCH. MECHANICAL (We) agree to save, indemnify and keep hufmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which pERMIT ISSUANCE 3.00 CONST.TAX may in Ay way'ucerue agams d City in Asequence of the gran( (this ernsi[ I MECH.CONT. LIC.NO. MECH. y 'dior TOTAL TOTAL S .cure of Applicant/Conine Uma OFFICE COPY