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1779 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION - PERMIT NUM ER Vy , ti ADAPPLICATION & PERMIT DRESS f��jn BUILDING - ELECTRICAL-PLUMBING -MECHANICAL ANERE - PLAN CHECK Vftla ATION MI;�f OTV. ELECTRIC PERMIT FEE NA OPHONE CONTRAC-R S uAM 1 OUTLETS-SWITCHES-RECEP 5.00/1.00 Jr� LC4V L LIGHTING FIXTURES 5.00/1.00 COONTRA TOR$ADDREAPPLIANCES-RESIDENTIAL 4.00 r PNONE Q PANELS A 5.00 DATE OF APPLICATION CHITECTLAN CHECK FEE P.C.NO. on SIGNS 6.00 0 ENGINEER LIC NO. ISIGNS TRANS. 3.00ARCH.OR AGGRESS ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 15.00 ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 f o o LICENSED CONTRACTORS DECLARATIONCITY ' a U CUPERTINIJ I hereby affirm that I am licensed under provisions of Chapter 9 a ISSUANCE DATE wO p1 (commencing with Section 7000)of Division 3 of the Business and 'BLDG. ELECT. PLG. MECH. r p i Professions Code, m lice is in full for jp f ❑ ❑ z 0%- LicenseNumber ZZHN 8 1982 g] 0 L E Date n s -ComraGor /'.Co , IS x w u OWNER-BUILDER UECLARATI ON ( - BUILDING PERMIT MISC.- .. TO ORD _ INFORMATION Ba ",,; u y I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT. r u 0 4 Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE _ 6.00 •A, ,A� Code:Any city or county whichrmluires'aperntitloeonslruel,alter, Ec ac G O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEG u requires the dp pursuant for such permit to file a signet statement that TOTAL PER e w S re ui licensed pursuant to the provisions of the Contractor's tatem statement that vd/ t- zve Law(Chapter 9(commencingwilh Section 7000)of Division 3 ofthe 4 O Business and Professions Code)or final he Is exempt therefrom and BE H 0 the basis for the alleged exemption.Any violation of Section 7031.5 GTV. PLUMBING PERMIT FEE STORIES TYPE CONSTR. u g by any applicant for u permit subject,the applicant Waeivil penalty 0� of not more than five hundred dollars(S500l): ALTER-DRAIN&VENT-WATER (EA.) 4.00 ❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS their sole compensation,will do the work,and.the structure Is not intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 Code',The Contractor's License Law docs not apply to an owner of property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 So.FT FLOOR AREA TOTAL ACREAGE himselfre through his own employees,s provided thus such improve. ,�- memsarenotimhhis oroffered oyee sale.Iided that such building GAS-EA.SVSTEM-11NC.40UTLET$ 4.00 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE builder will have the burden of proving that he did not buildor im- RES IND CON PB ' Omar prove for purpose of sale.); INDUSTRIAL WASTE INTER. 20.00 © -n El El El ❑ 1,as owner of the pro Perly,um exclusively contracting with. licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. and Professions Code:'flic Contractor's License Law does not apply to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 r contracts for such projects with a contractotls)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/5.00 file Contractor's License Law. TRACT NO. PARCEL NO. ❑ tum exempt under Sec..,B.&P.C.for this reasonWATER HEATER W/VENT 4.00 Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO. WORKERS'COMPFNSAIION DECLARAIION' WATER TREATING EQUIP. 4.00 1 1¢reby affirm that I hav6 a cerlil'ivafe of consent to self-insure, or a certificate of Workers'Compensation Insurance,or a certified ONING ENG.SITE NO, copy t hereof(See 3800 Policy en CompanyPant' 0 ❑ Certified copy is hereby fu rnis Ld. Z ZCerci y{�copy i5 it[, he city inspection diVi,ion, FIRE SPRINK ENERGY T-24 O ppb ant MISC.- REFER TO ORD. - f�, D W CERTIFICATE OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 - FLOOD ZONE � .6d L7 LU COh11'F.NSATION INSURANCE PLG.CONTR. LIC.NO. PLG. N CL 0 (This section need not he completed if the permit is for one TOTAL �, v Z hundred dollars IS 100)or less) L) O 1 certify that in the performance of the work I'ur which thisper- GTV. MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued, I shall not employ any person in any Banner so as to U 0 beconta subject to the Workers'Compensation Laws of California. 0. ow Date Applicant BUILDING } W NOTICE TO APPLICANT. If,atter making this Certificate of fix- ALTER OR ADD TO MECH. 4.00 H Z emption,you should become subject m the Workers Compensation APPLIANCE 4.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE U such provisions or this penuil shall be deemed revoked. AIR.HANDLING UNIT(TO 10=C.F.M.) 3.00 CONSTRUCT ION LENDING AGENCY AIR HANDLING UNITIOVER I0010C.F.M.) 5:00 SEISMIC FEE a � I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 tilt Performance of the work for which this permit is ivxued(Sec. MICROFILM 3097,Cie.C.). A /O,.f� HEATING UNIT (TO 100,000 B.T.U.) 4.00 Lender's Name /V �-/ HEATI NG UN IT 100,000 B.T.U.)7.50 Lender's Address ELECTRIC 1 certify that I have read this application andstate thal•Iha above VENTILATION FAN (SINGLE) 3.00 information is correct. 1 agree to comply wish all city and county PLUMBING ordinances and slate laws relating to building construction, and BOILER-COMPI3 H.P.Gr 100,0006.T.U.1 4.00 /O hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL' above-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 any im any way accrue against said City inconsequener of the I PERMIT ISSUANCE 3.00 grand n of this permit. MECH.CONT. LIC NO. MECH. 4 (0A TOTAL TOTAL TOTAL L� Sig aRl to of Applicant/contractor Date OFFICE COPY