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9354 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING . APPLICATION & PERMIT 9354 ,�. ADDRESS Oz E BUILDING-ELECTRICAL-PLUMBING-MECHANICAL � OWNER'S/9��'� /�� PLAN CHECK VALIDATXION NAME /� ' QTY. ELECTRIC PERMIT FEE 12ysamraPRON NAME ncTORs UTLETS-SWITCHES-RECEP 10.00/1.00 LIC.NO. LIGHTING FIXTURES 10.00/1.00 ADR's - APPLIANCES.RESIDENTIAL 4.00 CONDTRARESS PHONE PANELS 10.00 DATE OF APPLICATION ARCaUTECT PLANCHECKFEE P.C.NO. OR PANELS (OVER 200 AMP) 20.00 ENGINEER Llc.rvo. ISIGNS TRANS. 3.00 AARCH.OR DDRESS ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ' ZIP TEMP.METER OR POLE INS. 20.00 /I APPLICANT ADDRESS MOTORS SEE FEE SCH. �, �'�'�-0.• J AP SERVICE CHANGE 20.00 02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 a z U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE Haw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. r D w Professions Code,and my license is in full force and effect. ❑ ❑ El o y License ClassLic.Number O y F. Date Contractor a m f BUILDING PERMIT a OWNIi R-BII1LDIiR DECLARATION a o d u INFORMATION ^. w ; a.y I hereby affirm that I am exempt from the Contractor's License MISC. REFER TO ORD F LL o to Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT. Code:Any City or county which requires a permit to construct,alter, fe ¢ ¢ improve,demolish,or repair any stmdure,Prior to its issuance,also ELEC.CONTR.- LIC.NO. ELEG. i a- m Ie requires the applicant lot such permit to file a signed statement that TOTAL PERMIT TO he is licensed pursuant to the provisions of the Contractor's License F z¢ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe 4 o Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMITFEE M r$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. i by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00 of not mom than five hundred dollars(5500).1: ❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 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 ProfessionsDRAINS-FLOOR,HOOF,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 SQ FT.FLOOR AREA TOTAL ACREAGE himself re through ito his own employees.Provided that r,such improve- oments rimprovemenntsndadoroffuoneyeaalc.if,mpletion the the owing GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 or builder will have is sob within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 builder will have ale burden of Proving that he did not build or ire- BUILDING USE prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omar ❑ I,as owner of the property,am exclusively contracting wi lh licensed contractors to construct the projeel (Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. 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-OVER 5(EA.) 1.00 contracts forsuch projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200th/10.00 the Contractor's License Law. TRACT NO. PARCEL NO. ❑ I oat exempt under Sec.-,B.&P,C.for this WATER HEATER W/VENT fi.00 IXreason owner' ,te - - WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. / \ WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate of consent to self-insure, or a certificate of Workers'Compensation Insurance,or a tertif ied ZONING ENG.SITE NO. copy thereof(Sec.3800,Lab.C.). Policy No. Company Q ❑ Certified copy ishereby furnished FIRE SPRINK ENERGY T44 Z Z ❑ Certified copy is filed with the City inspection division. MISC.- REFER TO ORD. ❑ ❑ o � Applicant V N V N N CFR1'IFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. LU > COMPENSATION INSURANCE, PLG,CONTR. LIC.NO. PLG. CL 0 (This section need not be completed if the permit is for ono TOTAL Y❑ NC] Y 0 'N❑ hundred dollars IS 100)or less.) U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY IL P n.it is issued,I shall not employ any person in any manner so as to - O W become subject to the Workers'Compensation Laws ol'California. C. Date Applicant ALTER OR ADD TO ME 5.00 BUILDING } W NOTICE TO APPLICANT: If,after making this Certificate of Ex- F2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK Provisions of the Labor Code, you must forthwith comply with C.ffFEE U such provisions or this permit shall be III revoked AIR HANDLING UNI ( 10 ( 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MCC.F.M.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(19 5.00 the performance of the work for which this permit is issued(Sec. MICROFILM 3097,CN.C.). _ HEATING UNIT(TO 100,000 B.T.U.) 8.00 ' Lender's Name H EATING UN IT(OVER 100,000 B.T.U.)9.50 Lender's Address 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 PLUMBING �. oNimmees and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 ,Q, hereby authorize representatives of this city to enter upon the 801 LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL P�V above-mentioned property for inspection Purposes, •�, (We) agon.'t.Save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE . - 10.00 W CONST.TAX may in any way accrue against said City in consequence of the O granting of this permit. MECH.CONT. LIC.NO. MECH. ) TOT"` a .Qp TOTAL Shgnamrc o Appbcam/Commcmr Datc �(/ OFFICE COPY