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09673 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROilECT IDENTIFICATION •APPLICATION.St PERMIT„ PERMIT NUMBER 0.9 6 7 3 °nDING a O ES / f BUILDING -ELECTRICAL-PLUMBING-MECHANICAL , OW NE 's - PLAN CHECK VALIDATION �51 NAm TY. ELECTRIC PERMIT FEE PNGNE�aU/ CONTRACTOR'S NAME UTLETS•SWITCHES-RECEP 10.00/1.00 T. g coold-1 ua NG. `L LIGHTING FIXTURES 10.00/1.00 CONTRA AAPPLIANCES-RESIDENTIAL 4.00 eTRA )O CNE- [\ PHONE „� PANELS 10.00 DATE OF APPLICATION Aw- T - PLAN CHECK FEE P.C.NO. .. OR PANELS (OVER 200 AMP) .20.00 ENGINEER N'a Pc IEK uc.No.iZ6D 13. SIGNS TRANS. 3.00 f ' ARCH.OR ENG. - _ PERMIT VALIDATION ARCH OR I SPECIAL CIRCUIT 5.00 PERMIT ZIP TEMP.METER OR POLE INS. 20.00 APPUCANT•s MOTORS AOOR ESS SEE FEE SCH. SERVICE CHANGE 20.00 �� �,� 1985 wO o LICENSED CONTRACTORS DECLARATION TEMP.POLE' 30.00 Q''EE Fi W I hereby affirm that 1 am licensed under provisions of Chapter 9 I ""IK �Q DATE a (commencing with Section 7000)of Division 3 of Lha Rusiness and - BL EL T. 'F N i Professions Code, d my license is in full for�'�ytnil a Iec. Z,z N o License Class Lie.Number-7�b Yom_ FNH J Date 4.- > -gs Cnntmctor' a.m s c IBUILDING FERMIT ¢ ¢ a - OWNER-BUILDER DECLARATION ¢ w er i INFORMATION a'xt ;' y 1 hereby affirm that I am exempt from the Contractor's License MISC:- REFER TO ORD Lo¢ Law for the following reason.(Sec.7031.5,Businessund Prol essions PERMIT ISSUANCE ' 10.00 .VALUATION S/FT. � - Code:Any city or county which requires a permit to construct,alter, - - � / 111 J ce ¢ ¢40 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. 'LIC.NO. ELEC /� re w m¢ ,requires the applicant for such permit to file a signed statement that TOTAL/ ! (/V PERMIT TO he is(Chapter 9(co al to fine provisions of the Contractor's License - ,r - � rzi Law(Chapter')(commencing with Section 7000)ofDivision3 ofihe I i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢ m the basis for the alleged exemption.Any violation t t.ection 703 ity STORIES TYPE CONSTR. d3 _ by any applicant lorupermifldedla,($500plicum toacivil pewlty ALTER-DRAIN -WATER (EA.) 5.00 /�M of not more ]ran five hundred dollars 18500).): •J I_ ❑ I,as owner of the property,or my employees with wagesas BACK FLOW PROTECT.DEVICE 4.00 their sole compensation,will do the work,and the structure is not OC .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 SG.FT.FLOOR AREA TOTAL ACREAGE mentahimself re of rote his own employees,provided that such improve- - ments are not inch his or offered res,or lirovided that s the building. GAS-EA.SYSTEM'-1 1NC.40UTCETS 6.00 or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVERA IEA.) 2.00 110 I builder will have the burden of proving that he did not build or im- BUILDING USE Prove for purpose(if sale.). INDUSTRIAL WASTE INTER. 30.00 IND CON PB Orion ❑ I,as owner of the properly,am exclusively contracling with El ❑ 11 licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Code:The Contractors 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 forsuch projeatswitha contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200{1/10.00 Lire Contractor's License Law. I TRACT NO. PARCEL NO. ❑ I am exempt under Sec. ,B.RP.C.for this WATER HEATER W/VENT 6.00 . reason Owner Date WATER SYSTEM 5.00 ACC.DAIIE ACC.FILE NO. 0333 b WOR'ERS'COMPENSATION D17CLARATION WATER TREATING EQUIP. 5.00 I lit-4' vm ret I have a certificate of E.R,cnt to w1pinsure, or a cerlil'icale of Workers'Comin"I's hon insurance,or a certified ZONING ENG.SITE NO. copy thereof(Sec.3800,La b.C.). t- Policy Nn. Company-L{..rGl-/[ter.-- F' 1 PUP PJF O ❑ Certified copy is hereby far.fished. FIRE SPRINK ENERGYT24 _z Z CvrH�fic Is fluA wja the city inspection Division. MISC.- REFER TO ORD. O n Iicani L/� !A v N v N� ~ y PERMIT ISSUANCE 10.00 CERTIFICATP-OF EXIMPTION FROM WORKERS' FLOODZONE A.LU.C. LU > COMPENSATION INSURANCE PLG.CONTR, LIC.NO. PLG. CL Z )This section need not he completed if the permit is for one TOTAL, / Y N Y [] N hundred loran,IS 100)or less.) U O 1 certify that in the performance of the work for which)his per- QTY. 'MECHANICAL PERMIT FEE FEE SUMMARY LL U mit is issued,1 shall not employ any person many manner so as to , 0 W become subject to the Workers'Compensation Laws of California. ' Dmc Applicant BUILDING } N NO1'ICI7 'TO APPLICANT: II',alter making this Certilicam_of Ex. ALTER OR ADD TO MECH. 5.00 H ? creation,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 10OMC.F.M.) 4,00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 / the performance qG-tjm work f r which this nit is issued)Sec. MICROFI LM 097,Civ.C.l. rL���'Q 5 HEATING UNIT(TO 100,000 B.T.U.) 6.00 Lender's Na dr C/ HEATING UNIT 100,000 B.T.U.)9.50 Lender's Ad s3(�.�£V€N$ ELECTRIC W 1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 information n correct I agree to comply with all city and county - PLUMBING ` •�� information and scute laws relating m building,construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 hereby entionauthorizerepresentatives for ins inspection this city to enter upon Ina BOILER-COMP Over tolSooO RTU)SEE FEE SCH. MECHANICAL ©0 above-mentioned property forinsp of Purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. yM Cupertino against liabilities,judgments, costs andexpenseswhich PERMIT ISSUANCE 10.00 CONST.TAX W may in��ny way accrue against said City in consequence of the .' graRtlnng of sPermii. MECH.CONT. LIG NO. MECNJ Til WrvN_, �i-a�-BS TGT TOTAL Shunter,of Ap imant/C ntr etor Uate - ' - OFFICE COPY