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8263 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT ADDRESS BUILDING - ELECTRICAL-PLUMBING-MECHANICALO^ - H 8263 OWNERS PLAN CHECK VALIDATION aaa'''��G)R`� QTY. ELECTRIC PERMIT FEE �r PHONC cANT.Acroa A E UTLETS-SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 f,ONTRACTOR'� 13 PPL(ANCES-RESIDENTIAL 4.00 ADO.ESS ll/1� I^�'''�() PHONE a9T�C1 PANELS 10.00 DATE OF APPLICATION ARC ,TL on PANELS (OVER 200 AMP) 20.00 PLAN CH ECK FEE P.C,NO. ENGINEER LIC.NO. SIGNS TRANS. 3.00 ARCH,OR ENG. SPECIAL CIRCUIT S.00 PERMIT VALIDATION ADDRESS ZIP TEMP.METER OR POLE INS. 20.00 APPLICANT'S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 w o o LICENSE])CONTRACTORS DFCLARA'rION TEMP.POLE 30.00 u U 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCCE DATE h z sew (commencing with Section 7000)of Division 3 of the Business aW BLDG. ELECT. PLG. MECH. H H z Professions Cod nd-sn s nse is in full f nJ C `s z o w- License Lie.Numb�•t�Q ❑ ❑ ❑ 9 z H Uate �� .__Contracmrll{yi aYf ¢ w ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT o a " MISC.- REFER TO ORD INFORMATION X Say 1 hereby affirm that 1 am exempt front the Contractor's License VALUATION b/FT. F LL m j Law for the following reason.(Sea 7031.5.Business anJ Professions PERMIT ISSUANCE 10.00 Code:Any city or county which requires a permit to construct,alter, Be R¢0 improve,demolish,or repair any structure.pno,ID its issuance,also ELEC.CONTR. LIC.NO. ELEC. wDLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT Tpp$ he is licensed pursuant to the provisions of the Contractor's License / �L Law(Chapter 9(commencingwith Section 7000)of-Division 3 ofthe �'• ¢ Business and Professions Code)or that he isexcmpt therefrom and OTY. PLUMBING PERMIT FEE ¢ o lite basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR. by any applicant for a permirsubjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00 ofnol more than five hundred do1lrrs($500)J: ❑ 1,as owner of tie property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 their sole compensation,will do the work,and ttr he suclurc is not OCC.GROUP RES.UNITS intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 sO.FT FLOOR AREA TOTAL ACREAGE • himself re through his own employees,provided that such improve hients mself n through intendeughhis or empld ac,s.or provided that s the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00 or improvement is sold within one year of completion, the owner- GAS-EASYSTEM-OVER 4 IEA) 200 BUILDING USE builder will have the burden of proving that h . . . e did not build or im- RES IND CON PB Omar prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑ ❑ I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business LAWN'SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. aI Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. . ❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORK Ii RS'COM PENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm Ihut I have a certificate of consent to self-insure, ZONING ENG.SITE NO. or a certificate of jw$o(rrkkerss''6Coomyp�ensationn�Insurance,or a certified copy the S.- l- V, AS Policy N Q ❑ tdied copy is hereb furnished. FIRE SPRINK ENERGY T24 Z Z Certffu�x,Tws�_1s��f�yy ��•F ty inspection division. MISC.- REFER TO ORD. O npplicant�1F111� 1 KJiI ��T Y ❑ N❑ Y ❑ N❑ W CERTIPICA'I'F 01:E LX MI'I'[ON PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U,C. L31 >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ v ❑ N❑ d (This section need not be completed if the permit is for one TOTAL Z) Z hundred dollars IS 100)or less.) U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued.I shall not employ any person in any manner so as to Ow become subject to the Workc,S'Compensation Laws of California. BUILDING Dme Applicant ALTER OR ADD TO MECH. 5.00 } y NOTICE TO APPLICANT: If,after making this Certificate of IS x.. F Z eruption,you Shedd become subject to the Workers'Cnmpensaliun APPLIANCE 5.00 PLAN CHECK provisions of the Libor Code, you must forthwith comply with FEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.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 the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM 3097,Civ.C.L I, Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC Lender's Address I certify that I have read this application and stare that the above VENTILATION FAN (SINGLE) 4.00 information is correct. I agree to comply with all city and county� BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING ordinances and slate laws relating m building construction. and 1 -. hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 10Q000BTU1SEE FEESCH. MECHANICAL �« above-mentioned property for inspection purposes. -� 01 agree to save, indemnify and keep harmless the City of MISC.- REF R TO RD. Cupertino against liabilities,judgments, costs and expenses which I CONST.TAX may in any way accrue against said City in consequence of the PERMIT ISSUANCE .00 m of I is ermit MECH.CONT. LIC.N . MECH. Ua�l TOTAL TOTAL TOTAL i n wre of Applicarht/ ontractor at �4Xt`11 Q4J0��'IC1 OFFICE COPY