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10942APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POIPrT PEP! ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER BUILDING ADDRESS 445 rosy 3tcfsS0,A•s lt0.1VF BUILDING - ELECTRICAL- PLUMBING - MECHANICAL 10942 OWNER'S PLAN CHECK VALIDATION NAME �Ta,'IC-J / I7IL/L /huA1 PHONE 973-go7 QTY. ELECTRIC PERMIT FEE CONTRACTORS - NAME OUTLETS -SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 LIC. No. CONTRACTORS AODR Ess APPLIANCES 4.00 PANELS 10.00 PHONE DATE OF APPLICATION ARCHITECTPANELS DR ENGINEER uc. rvo. (OVER 200 AMP) 20.00 PLAN CHECK FEE D.C. N0. SIGNS TRANS. 3.00 ARC H.OR ENG. ADDRESSZIP SPECIAL CIRCUIT 5.00 PER MIT VALI DATION rrEMP. METER OR POLE INS. 20.00 AS - ADDREDDRESSS MOTORS SEE FEE SCH. %yS /LOSE 3LOSSOM k, GkhEL77tit SERVICE CHANGE 20.00��/ V [/ LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class Lic. Number Date Contractor ISSUANCE DATE BLDG. D ELECT. PLG. MECH. E _I) OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law forthe following mason. (See, 703 1.5, Business and Professions Code: Any city or county which requires a permit to construct, altef' BUILDING PERMIT INFORMATION MISC. - CM OMWO41ORD PERMIT ISSUANCE 10.00 Q '--� IO VALUATN $/FT. ELEC. CONTE. LIC. NO. ELEC. TOTAL - QTY. PLUMBING PERMIT FEE improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit t0 flea signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and PERMIT TO _ ELC C.T the basis for the alleged exemption. Any violation Of Section 7031.5 STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant ton civil penalty of not more than five hundred dollars ($5000.): ALTER -DRAIN -WATER (EA.) 5.00 ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not BACK F LOW PROTECT. DEV ICE 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 property who builds Or improves thereon, and who does such work himself or through his own employees, provided that such improve- mentsarenotintended or offered for sale. If, however, the building FIXTURES - PER TRAP 5.00 GAS-EA.SYSTEM-I INC-40UTLETS 6.00 SO.FT. FLOOR AREA TOTAL ACREAGE LIimprovement is sold within one year of completion, t e owner- builder will have the burden of proving that he did not build or im- prove for purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with GAS - EA. SYSTEM - OVER 4 (EA-) 2.00 BUILDING USE RES IND CON PB other ❑ 0 ❑ 0 ❑ INDUSTRIAL WASTE INTER. 30.00 licensed contractors to construct the project (Sec. 7044, [justness 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 contraclor(s) licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCELNO. , ❑ tum exempt under Sec. ,B.&P.C. for this reason L WATER HEATER W/VENT 6.00 Owner Datc WATER SYSTEM 5.00 ACC. DATE ACC, FILE NO WATER TREATING EQUIP. 5.00. WORKERS'COMPENSATION DECLARATION ��� I hereby affirm that I have a certificate of consent to sell-ins¢e, or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy thereof(Sce. 3800, Lab.C.). Policy No. Company FIRE $PRINK Y[] IN ENERGY T-24 v❑ N� ❑ Certified copy is hereby furnished. ❑ Certified 'copy is Filed with the city inspection division. Applicant MISC-- REFER TO ORD. CERTIFICATE 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. COMPENSATION INSURANCE (This Section need not be completed if the permit is for one Y [] N Y ❑ N PLG. CONTE. LIC. NO. PLC. TOTAL hundred dollars IS I00) or less.) I certify that in the performance of the work for which this per- mit is issued, 1 shall not employ any person in any manner so as to QTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of California. Date Applicant ALTER OR ADD TO MECH. 5.00 NOTICE TO APPLICANT: If, after making (his Certificate of Ex- 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 10,000C.F.IA) 4,00 AIR HANDLING UNIT (OVER I0,000GEM-) 6.00 SEISMIC FEE CONSTRUCTION LENDING, AGENCY 1 hereby affirm flint 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 H EATI NG UNIT (OVER 100,000 B.T.U.) 9.50 ELECTRIC VENTILATION FAN (SINGLE) 4.00 1 certify that I have read this application and state that the above information is correct. I agree to comply with all city anti county ordinances and slate laws relating to building construction, and PLUMBING BOILER- COMP(3 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 to enter upon the 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 may in any way accrue agai t said Ci ly in consequence of the CONST. TAX PERMIT ISSUANCE 10.00 granljpg of is pe %1,& �yU1 3I MECH. CONT. LIC. NO. MECH. TOTAL TOTAL (gnature of AppIkon[/Con[r�clnr ate UFFIUE CUPY