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11402 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER APPLI19ATFON & PERMIT BUILDING ADDRES zS t BUILDING —ELECTRICAL—PLUMBING—MECHANICAL 11402 ER5 EcrJei ups Avg Gc OwNP'S PLAN CHECK VALIDATION NAME yob ylry� QTY. ELECTRIC PERMIT FEE U ii;A L&01S PHONE �Y� Y/t/✓ MTORS NAMEE OUTLETS-SWITCHES-RECEP 10.00/1.00 NA LIC.NO. LIGHTING FIXTURES 10.00/1.00 CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00 ADDRESS PHONE PANELS 10,00 DATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK7 P.C.NO. OR ENGINEER LIC.NO. SIGNS TRANS. 3,00 ARC H.OR ENG. PERMIT VALIDATION ADDRESS SPECIAL CIRCUIT 5.00 ZIP frEMP.METER OR POLE INS. 20.00 AEMOTORS SEE FEE SCH. ADDRDDRESSSS SERVICE CHANGE 20.00 Cirri oO LICENSED CONTRACTORS DECLARATION u w 1 hereby m rov ' ISSJDAp yz (commencing with Section 7000)of Division 3 of the Business and ¢ ,a„ BLDG. ELECT. PLG. MECH. r y z Professions Code,and my license is in full force and effect zo z w W License Class Lic.Number Date Contractor a m F -J+ BUILDING PERMIT ¢ ¢¢ OWNIiR-BUILDER DECLARATION ¢wt- INFORMATION X ;LL H I hereby affirm(hal 1 am exempt from tare Contractor's License MISC.— REFER TO ORD w VA WATION $/FT. H .. O¢ Law for the following reason(Sec.703 L5,Business and Professions PERMIT ISSUANCE 10.00 Code:Any city orcounty which requires a perm it to construct,alter, re a¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ca O LL requires the applicant fur such permit to file a signed statement that - TOTAL w$ he is licensed pursuant to the provisions of the Contr ctor's LicenseP/P PERMIT TO H 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 QTY. PLUMBING PERMIT FEE / ¢ R the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. w. by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars($500).): ❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS intended or offerer) for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's License Law does riot apply to an owner of propeHy who builds or improves thereon,and who docs such work FIXTURES.PER TRAP 5.00 SQ.FT.FLOOR AREA TOTALACREAGE himself or through his own employees,provided that such improve mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00 Or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 builder will have the burden of proving that Ire did not build or im BUILDING USE prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Cuba, ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ D F-1 ❑ licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I 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 for such projects with a contractor(s)licensed pursuant In the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft110.00 TRACT NO. PARCEL NO. ❑ lam exempt under Sec.—,B.&BC.for this WATER HEATER W/VENT .NO reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.0 I hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.L D Policy No. Company Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24 ZZ ❑ Certified copy is fled with the city inspection division. O Applicant MISC.- REFER TO ORD. v N v N� CC m PERMIT ISSUANCE 10.00 UJ — CERTIF ICATEPE EXEMPTION FROM WORKERS' U FLOOD ZONE A.LU.L. W ' D COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. _q Z (This section need not be comptewc! if file permit is for One TOTAL OL Y C] NE] V[] N0 hundred dollars IS 100)or less.) U O 1 certify that in fire performance of the work for which this per QTY MECHANICAL PERMIT FEE FEE SUMMARY UL U mit is issued, I shall not employ any person in any nsanner so as to become subject to the Workers'Compensat ion Laws of California. i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } rn NOTICE TO APPLICANT': If,after making this Certificate of Ex. I— Z emption,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 10=C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOC.EM.) 6.00 SEISMIC FEE I hereby affirm.that (here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 the performance of the work for which this permit is issued(Sec. MICROFILM 3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00 information is correct.I agree to comply with all city and county PLUMBING Ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 hereby authorize representatives of this city W enter upon the above-mentioned properly for inspection hip urposes. BOILER-COMP love,100,000 BTU)SEE FEESCH. MECHANICAL (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX may in any way accrue against said City In consequence of the granting of this permit. MECH.CONT. LIG NO. MECH. ��-,I�� " -3 � TOTAL TOTAL Sgmat re of ppl ntracmr Date OFFICE COPY