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13869APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PR APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 13869 - ON RnwBU .LDI6 ADDRESS ° IN G7 OwNER's NAME ' ' h• HC) P.NE QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION croR's NAME NAME OUTLETS -SWITCHES-RECEP 10,00/1,00 LIGHTING FIXTURES 10.00/1.00 LIc. No. DATE OF APPLICATION CONTA ACTOR S ADDRESS LnsPHON3� / APPLIANCES -RESIDENTIAL 4.00 PANELS 10.00 ARCHITECT OR ENGINEER LIC. No. PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C. NO. ISIGNS TRANS. 3.00 ARCH. SS ENc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION TEMP. METER OR POLE INS. 20.00 ZIP ADDRESSTs MOTORS SEE FEE BCH. SERVICE CHANGE 20.00 LICENS17D CONTRACTORS DECLARATION I hereby affirm that 1 am licensed under provisions of Chapter 9 SUANpE DATE (commencing with Section 7000) of Division 3 of the Business and Professions Code, and y heense is in fall fOrfR and Cffee License Class Lie. NumberEl BLDG. ELECT. PLG. MECH. ❑ Date 9-/6 -Bt7 Contractor L✓a/ G OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec, 7031.$, Bmanessand Professions Code: Any city or county which requirespermit la construct, at ter, BUILDING PERMIT INFORMATION MISC. - REFER TO ORD PERMIT ISSUANCE 10.00 VALUATION SIFT. ELEC. CONTE. _ LIG NO. ELEC. ' TDTAL tiTV. PLUMBING PERMIT FEE improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for Such permit to file a signed statement that his he is licensed pursuant to the provisions of the Contractor's License the Lew (Chapterand Business and Professions Code) or that he is exempt therefrom and Professions Codeng with Section 7s 00) iesem t Division 3 and PERMIT TO 6 � YY by balls for the alleged exemption. Any violation of Sec civil malty fora ivehanmilsubjeclsth500).)caN too civil penalty byany more of not more than five hundred dollars(5500).): !� STORIES S TYPE CON R. ALTER-DRAIN-WATER(EA.) 5.00 ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00 intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of FIXTURES - PER TRAP 5.00 GAS -EA. SYSTEM- 11NC.40UTLETS 6.00 SD. FT. FLOOR AREA TOTAL ACREAGE property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- mentsare not intended oroffered for sale. If, however, the building or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or im- prove for purpose of sale.). ❑ Las owner of the property, am exclusively contracting with GAS - EA. SYSTEM -OVER 4 (EA.) 2,00 - BUILDING USE RES INTI CON PB Other ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER.- 30.00 licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. contracts for such projects with a contractors) licensed pursuant to the Contractor's License Law. - SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑, I am exemptunder Sec.-. W&P.C. for this reason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 WORKBRS'COMPENSA'r10N DECLARATION 1 hereby affirm that I have u certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance, or a certified o. y 1 s I ( ZONING ENG. SITE NO. • - copy thereof ( Sec. 3800, Lab.C.I. Policy No. Company ❑ Certified copy is hereby furnished,5 ❑ Cer le E'atl Bed wi s th city inspection division. APPlicnn . s Y.'d .�ssT"'� -' FIRE SPRINK y ❑ ry❑ ENERGY T-24 y ❑ ry❑ MISC. - REFER TO ORD. !(}/�!1� CERTIFICATE OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 Id FLOOD ZONE A.L.UX. - COMPENSATION INSURANCE (This Sectiondollars need not I)C completed If the permit is for OTIC PLG. CONTE. LIC. NO. PLG. �� nn TOTAL CZ0 Y ❑ N ❑ V ❑ N ❑ hundred dollars (S 100) or less) I certify that in the performance of the work for which this per- m any manner so as to mit is issued, I shall not cnsploy any QTY. MECHANICAL PERMIT FEE , FEE SUMMARY BUILDING grs9gf becol �a 'act t the Worker ' men IfH n,U yqf C' "orm Data Applicant/� x - NOTICI7 TO APPLICANT': If, after liking this Certificate of E ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 PLAN CHECK FEE ' emption, you should become subject to the Workers' Compensation Provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT (TO 1Q000GF.M.) 4.00 AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY 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. 3097, Civ.C.). MICROFILM HEATING UNIT TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address HEATING UNIT (OVER 100,000 B.T.U.) 9.50 ELECTRIC VENTILATION FAN (SINGLE) 4.00 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 PLUMBING a o BOILER- COMPO H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL hereby authorize representatives of this city m enter upon the above-mentioned property for inspection purposes. MISC. - REFER TO ORD. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which nm m any way accrue, against said City in conseyuence of the ., PERMIT ISSUANCE 10.00 CONST. TAX g n Bg of (h)B permle.�y/ MECH. CONT. LIC. NO. MECH. d�i�C/o 7 �( h'7 TOT"` TOTAL Ignatur7bf pphcant/Contractor Date OFFICE COPY