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09584 APPLICANT TO FILL IN INFORMATIONWITHIN RED LINES - USE BALL POINT PEN ONLY _ BUILDING PROJECT IDENTIFICATION PERMIT NUMBER a°"°'"° APPLICATION &MPERMIT A°ORESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 09584 OwNER's - PLAN CHECK VALIDATION PRONE QTY: ELECTRIC PERMIT FEE CONTRACTORES NAME �y -OUTLETS,SWITCHES,RECEP 10.00/1.00 CLA6S LIGHTING FIXTURES 10.00/1.00 clENTRACTOR's PPLIANCES-RESIDENTIAL 4.00 ADORE / - \PHONE O ' PANELS 10.00 PATE OF APPLICATION ORRC ECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.L.NO. ENGINEER Lie No. SIGNS TRANS. 3.00 ADDRESS E"G' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION APPLICANT S ZIP EMP.METER OR POLE INS. 20.00 Irmly ADDRESSOREss MOTORS SEE FEE SCH. rY Alo SERVICE CHANGE 20.00 ' 71985 Woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /��I�f a u 1 hereby affirm that I am licensed under provisions of Chapter 9 11 SILO N < m (c.neo etch, clmn 7000)of Division of the Businesgand BLDG. ELECT. PLG. ECH. H z Professions s e, a License is in full f a `/ ❑ ❑ ❑ oi License class Lit.Number 61 Q xJ Da1cCmllractor a re Q OWNER-BUILDER DECLARATION. BUILDING PERMIT §: " MISC.- REFER TO ORD - INFORMATION a`xl 3' H I hereby affirm that 1 am exempt from the Contractor's License Hyw J Law forthe following mason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION E/FT. to Code:Anyehyorcounty which requires a permit lrc nstual,alter, ELEC.GDNTH, LIC.NO. SE S ta Q o improve,demolish,or repair any structure,prior 10 its issuance,also ELEC. aa a wO M requires the applicant for such permit to file a signed statement that TOTAL PERM T TO $ he is licensed pursuant to the provisions of the Contractor's License O 1IU r z t Law(Chapter 9(commencing with Section 7000)of Division 3 oflhc 4 o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE I- $ DIC basis for the alleged exemption.Any violation of Section 703 L5 - ' STORIES TYPE CONSTR. d3 _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars(S500).1: ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES,urv1T5 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. 5.00 Code:The Contractor's License law does not apply to an owner of properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE • himself or through his own employees,provided that Such improve. marts are not intended or offered for sale.If,however,on,building GAS-EA.SYSTEM-I1NC.40UTLETS 6.00 or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or Or. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE prove fnrpnrpose ofsale.). 19 IND CON PR Orhar' ❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 1:1 1:1 ED11licensed contractors to construct the project(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 for such projects with a contractous)licensed pursuant to tireSEWER-SANITARY Contractor's License Law. STORM EA.200ft/10.00 1 TRACT NO. PARCEL NO. ❑ 1 am exempt under Sec. ,B.&P.C.for this reason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC.GATE ACC.FILE NO, WORKERS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate o(eonsent to selhirsum, or a c�AN W0SI�r� satil�sus aretl' I ZONING ENG.SITE NO. copy IPL') ( '.@1;BQsL1� Policy Fo. Company O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24 Z Z 13 Certified ,,,QQQ111'''y��is filed with the city inspection division. I- O ADRlicant ` misc.- REFER TO ORD. Y❑ N❑ Y ❑ N❑ 2y CERTIFIATEOF IiXEh1PTIONFRONIW XERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. LL > COMPENSATION INSURANCE PLG CONTR. uc.NO. PLG, 0- 0( This section need not be completed if the permit is for one TOTAL Y❑ ,N❑ Y❑ N❑ U O hundred dollars IS 100)or IessJ . - I certify that in the lierfornuulce of the work for which chis per- CITY. MECHANICAL PERMIT - FEE - -S FEE SUMMARY s x LL 1- mit is issued, I shall not employ any person in any manner so as to O W became subject to the Workers'Compensation Laws of California. St. Dae-Ali ALTER OR ADD TO MECH. 5.00 BUILDING >_ N NOTICE TO APPLICANT: If,after making this Certificate of Ex- ? emplion,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 10MC.F.M.) 4.00 CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,0WC.EM.) 6.00 SEISMIC FEE 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. MICROFILM 3007,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC 1 certify that I have read this application and ,are Ihal the above VENTILATION FAN (SINGLEI 4.00 information is correct. 1 agree to comply with all city and county PLUMBING ordinances and stale laws relating to building construction, and BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. BOILER-COMP fOver 100000 BT 1$EE FEE SCH. MECHANICAL (We) agree to save, indemnify and keep harmless the City of MISC.- ER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANC 10.00 CONST.TAX may in any way accrue against said City in consequence of the gra o rmil yn M CONT. LIC.NO. MECH. _ V � TOTAL fit_ SI tune of pph�l Cont ¢tor �� Da ow (�t��// TOTAL OFFICE COPY