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8905 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTIFICATION PERMITNUMBER BUILDING APPLICATION & PERMIT 8905 ADDRESS BUILDING -ELECTRICAL-PLUMBING-MECHANICAL OWNER'S PLAN CHECK VALIDATION NAME . CITY. ELECTRIC PERMIT FEE N / (/Gu TRHONE CONTRACTOR UTLETS-SWITCHES-RECEP 10.00/1.00 / / LIGHTING FIXTURES 10.00/1.00 CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00 64 PHONE -p,� PANELS 10.00 DATE OF APPLICATION ARCHITECT PLAN CHECK FEE P.C.NO, OR PANELS (OVER 200 AMP) 20.00 ENGINEER Llc.NO SIGNS TRANS, 3.00 ARCH.Ess E"o' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION zip EMP.METER OR POLE INS. 20.00 ADDRESSAPPLICANMOTORS MOTORS SEE FEE SCH. J pEr c z ��ifl�ES �• SERVICE CHANGE 20.00 , 02 LICENSED CON'I'RACTORS4 :CLARATION TEMP.POLE 30.00 +f a v Fj I hereby affirm that I am licensed under provisions of Chapter 9 btflUA190MOAlE., _ ,HA c i (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT.- ECH. F y i Professions Cod and my license is in full force and it 'rJ Z O m- License C ss�/ _Con Number. ❑ ❑ I ❑ -�0_ w Lice Contractor Q y 3 J ¢ i OWNER-BUILDER DECLARATION oBUILDING ERMIT w 0,w 1 hereby affirm (list 1 am exempt from the Contractor - REFER TO ORD INFORM TION 's License MISC. u 0 4' Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT. F - PERMIT ISSUANCE 10.00 3040 improAnycityor countywhiny structure permit toconsuance,also 2 E ¢ 0 improve,dem Ish,or repair any structure,prior to its Issuance,also ELEC.CONTR. LIC.NO. ELEC. DLL requires the up kart for such permit la file a signed statement that TOTAL PE IT T E $m he is licensed pu ant to the provisions of the Contractor's License Fir Law(Chapter9(col encingwi lh Section 7000)of Division 3ofthe i 0 Business and Professio ode)or that he is exempt therefrom a DTV. PLUMBING PERMIT FEE A 1 F 8 the basis for the alleged ex tion.Any violation of Section 7 .5 STO IE TVP CONSTR. I e. 3 by any applicant fora permit jeers the applicant tnaciv' enalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 of no[more than five hundred d rs(85001.1: ❑ I,as owner of the property, my employe with wages as BACK F LOW PROTECT. DEVICE 4.00 DCC.OR P R S.UNITS their sola compensation,will do the k,and etmcture is not intended or offend for Sale (Sec. 7044, u' Ess and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's License Law does apply to an owner of property who builds or improves therea ,an ho docs such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employee provided t such imProvr ments are not intended or offered r sale.If.howcve, I,building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 or improvement is sold within a year of completion,Ili watt- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 builder will have the burden proving that he did not bait or im- BUILDING USE prove for purpose ofrale.) INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer ❑ 1,as owner of th roperly,-anl exclusively contracting with licensed contractors wnstruct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions C he Contractor s Llconw Law does not apply to an owner o roperty who builds or improves thereon.and who LAWN SPRINKLERS-OVER 51EA.) 1,00 contracts for such projects with a contmctods)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORMEA.200ft/10.00 TRACT NO. PARCEL NO. ❑ Inn exempt under Sec.lenson ,Ii.&P.C.for this / WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.PILE NO. WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby ufflrm that I have a certificate of consent to self-insure. ar a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO. copy thereof Se .3800,Lab C.). Policy No-f�WCompany d/71Fh nd -7_as 0 ❑ Certified copy is batch y furnished FIRE SPR INK ENERGY T-24 t Z Z -sla, Cerl`iiec l d y is fed with 1 c ty IrKp coon division. F O Applicant J.nl /}-r�.l r; MISC.- REFER TO ORD. Y N Y NC3 N CERTIPICATI:OP EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 ,©, FLOOD ZONE A.L.U.C: UJ > COMPENSATION INSURANCE PLG.CONTR. ( LIC.NO. PLO, � 0 (This section need not be completed if the permit is for one 6/J7h/a�x,111e� TOTAL Y❑ N Y N[3 hundred 51001 or less.) U O I certify that m ormance of til or which this per, DTV MECHANICAL PERMIT FEE FEE SUMMARY LL F out is issued,1 shall not emp on in any mannerso as to O w become subject to the Work ompensatlon 4wsuLC (ornia. a Date A ant ALTER OR ADD TO MECH. 5.00 BUILDING } N NOTICE TO AP ANT: lf,after making Ibis Certificate of Ex- 2 empu.n,ye 'cold become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK provision 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=41F.M.) 4.00 CONSTRUCTION LENDING AGI7NCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE I hereby Im there is a construction lending u e 'EXHAUST HOOD (WITH DUCT) 5.00 the performance of Ile w h 111Issued(Sec. MICROFILM 3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 Lender's Add ' 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 BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL uhovo-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 r'd City in consequence of the PERMIT ISSUANCE 10.00 granng c(f is penni'. MECH.CONT. LIC.NO. MECH. TOTAL TOTAL Ignature of Applicant/Contractor Date OFFICE COPY