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0964 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - US� BALL POINT PEN ONLY p BUILDING PROJECT IDENTIFICATION - - PERMIT NUMBER ADLDINGDRESS APPLICATION & PERMIT 09664 ADDRESS • � � V� �La BUILDING-ELECTRICAL-PLUMBING -MECHANICAL NAM 'S PLAN CHECK VALIDATION NAME Q q . b- E37/-04{Od OTV ELECTRIC PERMIT ,FEE - A PHory NAME CONTRACTORS l NAME IIII ,Q UTLETS-SWITCHES-RECEP 10,00/1.00 f 4k. P 01 ..'(-' LICA /3�` 9 LIGHTING FIXTURES 10,00/1.00 CONTRACTORS ADDRESS a qq cc PPLIANCES-RESIDENTIAL 4.00 Vrssi 0.V PHONEp7!'p¢d0 PANELS 10.00 DATE OF APPLICATION A CH TELT PLAN CHECK FEE P.C.NO. OR PANELS (OVER 200 AMP) 20.00 ENc NEER -3 K� " a a� SIGNS TRANS. .3.00 LID. �= ADDRESS NG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION a 0 3 C-a,C e, KFV-� rP EMP.METER OR POLE INS. 20.00 PA�Dryry gg ADDRESS MOTORS SEE FEE SCH. SEP O � '.y®.7 ADDRESS J.S 1 a',. JY C r SERVICE CHANGE 20.00 , ' 0Dec2 r• D o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 CI Of Co rt v w 1 hereby affirm that I am licensed under provisions of Chapter 9 V InO a,a N (commencing with Section 7000)of Division 3 of the Business and DANCE A BLDG. ELECT PLG. MECH. r y z Professions Codr/2nd lny license is in full f e �ff�p{ ❑ ❑ ❑ o i m W Liccnsc ass_.Is! Lic.Numhe `,o 9 Dale Contractor Gy2 M ¢ w a OWNER-BUILDER DECLARATION ( BUIL NG PERMIT' wo e. o INF RMATION;,,t ; u.F I hereby affirm that I am exempt from the Contractor's License ISC.- REFER TO ORD - Fu0 J Law for the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT. Code:Any city orcounty which requires a permit to construct,alter, ¢ a a 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. TELEC. K m¢ requires the applicant for such permit W file a signed statement that OTAL n w he is licensed pursuant to the provisions of the Contractor's License PERMIT TO rii Law(Chapter 9(commencing with Section 7000)of Division 3ofthe _ a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE- rc =$ the basis for the alleged h d exemption.Any violation of Section malty STORIES TYPE CONSTR. by any applicant fora permit the penally ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars(5500)J: ❑ I,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 Professions DRAINS-FLOOR,ROOF,AREA,GOND. 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 5.60 SO.FT.FLOOR AREA TOTAL ACREAGE • himself or through his own employees,provided that such improve- ments are not intended or offered for sale.If however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 or improventenl is Sold within one year of completion,the owner. builder will have the burden of proving that he did not build or int- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDIN USE prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND C PB Olhe, ❑ I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS A CEL 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 conlmctorls)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.2008/10.00 TRACT NO. PARCEL NO. ❑ lam exempt under See,.,B.&P.C.for this reason WATER HEATER W/VENT 6.00 Owner Uwe -- WATER SYSTEM 5.00 ACC.GATE, PCC.FILE NO, WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have o certillcwe of consent to self-insure, or a certificate of Workers'I peasation Insure' e,.or a certified, ZONING ENG.SITE NO. copy Cher¢of/S©�$p3.3Nf J. ?11 Policy bukd 7u`Cpompany CL' F- J �+ O 1 0-cizAtified copy is hereby furnisl •d. Z Z '-Cepe r'fie Py is filed wit�I n clion division. FIRE SPRINK ENERGY T-24 F O Applicant MISC.- REFER TO ORD. Y ❑ N� Y [D NO Il y .RTI F I CAI'Ii O F 1' EMPTION FRO ORKI:RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. L COMPENSATION INSURANCE PLG,CONTR. LIC.NO. pLG. (This section need not be completed if the permit is for one TOTAL Y N Y N� Z hundred dollars IS 100)or ICSO U O 1 certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY' LL U mil is issued,I shall not employ any person in any manner so as to become Subject to the Workers'Compensation Laws of California. t Data Applicant ALTER OR ADD TO MECH. 5.00 BUILDING >_ to NOTICE TO APPLICANT: If,after making this Certificate of Ex- 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 C..1 such provisions or Ibis permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,f106C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE I hereby affirm that there is a conslnation lending agency for EXHAUST HOOD(WITH DUCT) 5.00 the performance of the work for which this permit is issued(Sec. MICROFILM 3097,Civ.C.T HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.)9,50 Lender's ess ELECTRIC I certify that l 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 BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING ordinances and state laws relating to building construction, and hereby authorize representatives fatties of this city to enter upon the BOILER-COMP(Over 100,000BTU)SEE FEE SCH. MECHANICAL above-mentioned property for tativspe of purposes. (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 ting of this pe it. MECH.CONT, LIC.NO. MECH. 14 TOTAL TOTAL gnature of pplicant/Co rector Date OFFICE COPY All