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5952 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER To'WING APPLICATION & PERMIT" A OORESS BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 5952 ONAME a `F=8'n -� " '"" �glFy As - 'p PLAN CHECK VALIDATION 1 (f/ — - ` QTY': T K,aECECTRIC`PERMIT «* I, � FEE A PHONE t 'S, ,.riq CONTRACTORS NAME `� OUTLETS-SWITCHES-RECEP 5.00/1.00 T LIC.NO. ala LIGHTING FIXTURES 5.00/1.00 _ - GONTEACTOR9i�DgSlPPLIANCES-RESIDENTIAL 4.00 r� NVvyt 1 PHON�,(—/LJ­0AO PANELS J 5.00 DATE OF APPLICATION ARCHITECT SIGNS S.00 PLAN CHECK FEE P,C,NO. DR CNGINEER ' uc,No. SIGNS TRANS. 3.00 ARCH.ss ENc. SPECIAL CIRCUIT 5.00 PERMITVALIDATION ZIP rrEMP.METER OR POLE INS. 15.00 CA I APPLS APPI CA - MOTORS, -SEE FEE SCH. SERVICE CHANGE 10.00 woo LICENSED CONf RACI'ORS DECLARATION rt v w '1 hereby affirm that I am licensed under pnwisinns of Chapter 9, ISSUANCE DATE yNcR unencing with Section 7000)of Division 3 of the Business and <u -I� O BLDG. ELECT. PLG. MECH. F m i P...(cssions C. E, my license on full h n effeSt T x ❑ ❑ ❑ ❑ Z o m.— License Class Lie.Numbe f—).l r w Date Ss U Contractor BUILDING PERMIT ¢ ¢o i o OWNER-BUILDER DECLARATION INFORMATION wg LL N I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD s- LL 0 as Law for the following reason.(Sec.7031.5,11minessand Professions PERMIT ISSUANCE 6.00 VA ti in vt Code:Any city or county which requiresu permit to construct,alter, i[�a� ¢ , ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO.' ELEC. T Do¢ requires the applicant for such permit to filo a signed statement that TOTAL MI a w mhe is licensed pursuant to the provisions of the Contractor's License i Law(Chapter 9(commencing with Section 7000)of Urvision 3 of the iao Business and Professions Code)or that he is exempt therefrom and QTY.YfF�a� syg s,PLUMBWGPE'RMIITti`y'+` FEE LR.oO� �Jz ¢r$ the basis for the alleged exemption Any violation of Section 7031 5 "" •"A, k CONSTR. a ; � by anyapplicant for. vehundpermit subjeco(the$50pplicam toacivilpenalty ALTER-DRAIN of not mom than five hundred dollars(my cm): a�t ❑ Las owner of the will do t or my,and t e s with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC. OUP RES.UNITS lith sole compensation,will(S the work,and the structure is not intended or offered for sale sect. 7044, Business end Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00 �o /V !LS Cole:Tye who License Law does not apply loan owner of property who builds or Improves employees, pr and who docs such work FIXTURES-PER TRAP 4.00 SO.FL FLOOR AREA" TOTAL ACREAGE himself m through his own eared for provided that such improve nienis ore not intended or offered far safe If,however,the building GAS-EA:SVSTEM-11NC.40UTLETS 4.00 or improvement is sold within one,year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.1 1.00 BUILDING USE builder will have the burden of proving Thal he did not build or am. RES IND CON PB Omer Prove for purpose of e.). h INDUSTR IAL WASTE INTER. 20.00 1:1 El El ❑ El I,ass owner th of the properly,am exclusively contracting with licensed contractors to construct the project ISce.7044,Busincas LAWN SPO IN KLERS=1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. and Professions Cnde:The Cmiton u-a License Law Jars 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 to the Contractor's License l.aw. SEWER-SANITARY-STORM EA.200ft/8.00 TRACTNO. PARCEL NO. ❑ I am exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 4.00 reason Owner - Data WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO, WORK RRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 I hereby of on that I have a Certificate of consent to selEinsum, ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified Copy thereof(Sec.3800,Lu1j.-) ,Policy No. Company�l�G TY9_7_ ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T-24 Z_ Z ❑ Cert i opy s i •d with the city inspection division. MISC- - REFER TO ORD. Applicant C V❑ N❑ V ❑ IN E] F— �+ PERMIT ISSUANCE 6.00 c CERTI I4CA' I'IiXIiMI'T NFROM WORKERS' FLOOD ZONE A.L.U,C. LU COMPENSAj'ION INSURANCE PLG.CONTE. LIC.NO. PLG. Z z (This section need not he completed if the permit is for one TOTAL Y❑ N❑ Y❑ NEI hundred doll...(S 100)or less,) - U O 1 certify that in the performance of the work for which this per. ° .t r § _k x' 'n ','xkaFE E+SUMARV c QTV•'A"�'. ,'-MECHANIQAL PERMIT . `•a+ sFEEA x, M LL I— mit is issued,I shall not employ any person in any mannerso as t y w ,„ `' S,e - Q w become subject to the Workers'Compensation Laws of California. n Dam 'Applicant ALTER OR ADD TO MECH. 4.00 BUILDING s"D f� } N NOTICE—TOAPPLICANT: IL after making this Certificate of F.x- F-. ? cmption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK prisions of the Labor Code, you must forthwith comply with U sucovh provisions or this permit shall be deemed revoked - AIR HANDLING UNIT(TO 10/100C.F.M.) 3.00 FEE CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10000 C.EM.) 5.00 SEISMIC FEE a� I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 the performance of the work for which this permit is.issued(Sec. MICROFILM 3097;GYC.I .. HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50 Lender's NaJress ELECTRIC I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 .information is correct. I agree to comply with all city and county - PLUMBING ordinances and sLate laws relating to building construction, and BOILER-COMP (3 H.P.Of 100,0008.T.U.) 4.00 hereby authorize representatives of this city to:enter upon the above-mentioned property for inspection purposes. BOILER-COMP(Over 100.000 BTU)SEE FEE SCH. MECHANICAL (We) agree In save, indemnify and keep harmless the City of MISC:- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX May in any way accrue against said City in consequence of the gr togofthispcRnitMECH.CONT. LIC.NO- MECH. TOTAL YOTAL�;' Signatumot Ap ant/ ontrac r Dale - OFFICE COPY ,