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12478APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 12478 BUILDING 54a 11 )0 ©r-40)00 OWNER'S .NAME : N r U) PHONE2�,7 /� O QTY. • ELECTRIC PERMIT FEE ., PLAN CHECK VALIDATION - ' , DATE OF APPLICATION PLAN CHECK FEE P,C. NO. CONTRa OGS - SOO.T �� NAME /� G E OUTLETS-SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 CONTRACTOR'S ADDRESS 14 +q \q 6P{1x8 S•J, PHONE Sll ARCHITECT • OR ENGINEER LIC. NO, APPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 PANELS (OVER 200 AMP) 20.00 SIGNS 'TRANS. 3.00 ARC H, OR ENG. I" ADDRESS - ' ZIP .SPECIAL CIRCUIT 5.00 PERMIT VALIDATION - M ✓/\ J TEMP. METER OR POLE INS. 20.00 APPLICANT'S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTFACTORS DECLARATION , - Thereby affirm that I am licensed under provisions of Chapter 9 (commemmng with Semon 7000) of. Division 3 or lire Business and ISSUAN E DATE BLDG. ELECT. PLG. MECH. Professions Cole an{Lmyliceveis inrtegpd�y,ay Lieenu Cla Lie. Numbc,mber_JV Ve El 11 1 Contractor , - BUILDING PERMIT OWNER -BUILDER DECLARATION - I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec. 7031.5, Business and Professions INFORMATION MISC. - REFER TO ORD VALUATION S/FT. PERMIT ISSUANCE - 10.00 - Code: Any city or county which requires permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also ELEC. CONTE. LIC. NO, ELEC. requires the applicant fur such permit 1r filo a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9(conmtuncing with Section 7000)ol Division 3'of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation o(Section 7031.5 by any applicant for a permit subjects the applicant toa civil pen ally of not more than five hundred dollars (S500f ): TOTAL • PERMIT TO QTY. PLUMBING PERMIT FEE ! STORIES TYPE CONSTR. ALTER -DRAIN & VENT -WATER (EA.) 5.00 BACK FLOW PROTECT. DEVICE . 4.00 OCC. GROUP RES. UNITS ❑ 1, as owner of the property. or my employees with wages as 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 (Hereon, and who does such work himself or through his own employees, provided that such improve- mentsarenetintendedorofferedfursale. ll', however, the building, FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE GAS-EA.SYSTEM-111NC.40UTLETS 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 un- prove for purpose or sale.). ❑ I, as owner of the properly, am exclusively contracting with licensed contractors to constructthe project (Sec. 7044, Business GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 BUILDING USE RES IND CON PB Omer ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 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. Bad 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-STORM ❑ lam exempt under Sec. ,B.&P.C. tort his EA. 200ft/10.00 TRACT NO. PARCEL NO. WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM - - 5.00 ACC. DATE ACC, FILE NO. WORK ERS'COMPENSATION DECLARATION " WATER TREATING EQUIP. 5.00 Ihereby affirm that I have acertificate fconsent to self -insure, or a certificate of Workers' Compensst ou Insurance, or a certified - - ZONING ENG. SITE NO. copy thereof(Sec. 3800. Lpab.Y.1. c 1'0l' No. Com an C -N Certified copy is hereby fardi d. A Icanti coQy isy wth he ci ms14 u tdivkkmo p w_�_� - , - '. FIRE gPRINK Y❑ N❑ ENERGY T 2 V❑ N❑ MISC.- REFER TO ORD. CERTII ICA'I'Ii OI° EXEMPTION FROM WORKIiRS: 'PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C. PLG. CONTE. LIC. NO. PLG. TOTAL 'COMPENSATION INSURANCE 'section need not be completed if the permit is for one y❑ N YE]NE] ' OTY MECHANICAL P RMIT FEE FEE SUMMARY hundred dollars IS IOD) or less.) I certify that in the'performance of the work for which this Per mit is issued, I shall not employ any person in any manner so as to become subject to the Workers' ComPensat ion Laws of California. Date Applicant BUILDING ALTER OR ADD TO Qj 5.00 NOTICE TO APPLICANT: If after making this Certificate OFL7, you should become subject to the Workers' Compensation provisions of the labor'Cude, you most forthwith comply with such provisions or this permit shall be deemed revoked. APPLIANCE C'i - •�.00 PLAN CHECK FEE AIR HANDLING UNIT (TO 49)OC.FkV 4.00 AIR HANDLING UNIT( .•10 .M.)6.00 SEISMIC FEE, ' CONSTRUC'T'ION LENDING -AGENCY EXHAUST HOOD (WITH D ) 5.00 MICROFILM I hereby affirm -that there isa construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ.C.). / HEATING UNIT ITR t00,0008.T.U.) 8.00 HEATI NG UN IT (OV ER 100,000 B.T.U.) 9.50 ELECTRIC Leader's Name Lmtder's Address - I certify that I have read this application and stale that the above information is correct. I agree to comply -with all city and county ordinances and state laws relating to building construction, and hereby authorise representatives of this city to enter upon the above-mentioned property for inspection purposes. ' (We) agree to save, indemnify and keep hmoless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against sa/d City i consequence of the VENTILATION FAN (SINGLE) 4.00 PLUMBING BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00 - BOILER'COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL - /� V MISC. - REFER TO ORD. CONST. TAX , PERMIT ISSUANCE 10.00 u,1 MECH. CONT. LIC. NO. MECH. TOTAL / TOTAL granlingo [1515 pe ignatureofA ant/Contracto Dee OFFICE COPY