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5057 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT 5057 O� r 1� aoonEss C / - J G.- BUILDING-ELECTRICAL-PLUMBING-MECHANICAL OWNER'S - PLAN CHECK VALIDATION "A"� - TY. ELECTRIC PERMIT FEE v PHONE CONTRACT ONT ACro s OUTLETS-SWITCHES-RECEP 5.00/1.00 NAM; .No. LIGHTING FIXTURES 5.00/1.00 CONTRACT a RE66 OLES - PPLIANCES-RESIDENTIAL 4;00 PRONE Z� '© PANELS 5.00 DATE OF APPLICATION ARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO. ENGINEER uc.No. SIGNS TRANS. 3.00 ADDRESS ENC. - SPECIAL CIRCUIT '5.00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 15.00 ASMOTORS SEE FEE SCH. ADDRESS ADOR G SERVICE CHANGE 10.00 F o o - LICENSED CONTRACTORS DECLARATION Q i w I hereby affirm that I am liwnsed under provisions of Chaplcr'J - ISSUA(((NCE DATE BL (commencing with Section 7000)of Division 3 of the Business anti m ¢ LE ❑ G.CT. PLMECH. H :ti Professions Code nd Rose is in full to -•f- z o y - License lass_ Lit.Nunn, ❑BLDG, E mDetc_ � Contractor - w u OWNER-BUILDER DECLARATION l BUILDING PERMIT X ;is ,_ N I hereby affirm teal I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION H u o J law for the following reason.fSec,7031,5,Businessandl'rofessions PERMIT ISSUANCE 6.00 VALUATION $/FT. > Code:Any city orcounty which requires a permit to conslract,alter, ¢ ¢ ¢ improve,demolish;or repair any xtrnet Lire,prior to its isamnee,also ELEC.CONTR. LIC.NO. ELEC. 4 X m LL flllnlres the apIlllCant for SRCII permitIn Elle a 4lgnfd 6tldellleN.Ihat TOTAL PERMIT TO he is licensed pursuant to the provisions of the Contractor's License HiQ Law(Chapter9(commencing with Section 7000)of Division 3 ofthe - 5 i 40 Business and Professions Code)or that lie is exempt therefrom anti OTY. PLUMBING PERMIT FEE M I- to the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. La a by any applicant for a permit subjects the upplicont to civil penally of not more than five hundred dollar,(S5000.) ALTER-DRAIN&VENT-WATER (EA.) 4.00 O Las owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP REB.UNITS sole compensation,will do the work,and the structure is not intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,EA,CON D. 4.00 Code:-The Contractor's Lictose Low does no apply to an owner of property who builds Or improves thereon,and who does SUCK work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE ,• himself or ihrough.his own employees,provided that such improve- ments are not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-11NC.4 OUTLETS 4.00 or.improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE builder will have the burden of proving that he did not build or inn- prove for purpose of sole.). RES IND CON PB Othef LlLas owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 20,00 ❑ 11 1 licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 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 forsuch projects with u contractons)licensed pursuant to the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO. ❑ I am exempt under Sec.-.B.&P.C.for this WATER HEATER W/VENT 4.00 reason Date Owner WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO, WORKERS'COMPENSATION UECLARA'I'ION WATER TREATING EQUIP. 4.00 1 hereby affirm that I Have a certificate of consent to self-insur'' ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec 3800,1.:Lb.C.1. - Policy Nore/� :ompanY p_'LLL_�- O ❑ CerhlTm�rJ copy is hereby famished, FIRESPRINK ENERGY T-24 Z Z' Ij�Certi fieil py fl I e cit inspection division. O Al(plicae! I -`'rT �d l MISC.- REFER TO ORD. Y � N❑ Y 0 NE] ~ rn T' PERMIT ISSUANCE 6.00 LU CER'I'IPICA MPENEAPION ION FROM FLOODZONE A.L.u.G, W COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG. Y N Y El N � ('Phis section need not he completed If the perndl is for one TOTAL 1-1 hundred dollars 1$100)or less.) U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY LL P mit is issued,I Shull not employ any person in any planner so as to O L)Y, hecome subject to the Workers'Compensation Laws of Cullrornia. a File Applicant ALTER OR ADD TO MECH. 4.00 BUILDING >_ m NOTICE TO APPLICANII If,after making this CLUBicale of Ex- ♦- ? emption,you should become subject to the Workeri Compensation APPLIANCE .00 PLAN CHECK Provisions of the Labor Code, you must forthwith comply with FEE U such provisions or this permit shall be decried revoked. AIR HANDLING UNIT ITO 1Op00QF.M. 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVE UCT) .) SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH D tine performance of the work for which this permit is issued(Sec' MICROFILM 3097,CtYC.). HEATING UNIT(TO 100 DO Lender's Nome HEATING UNIT 100,00013, . Lender's'Address - ELECTRIC I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 int'onnation is correct. I agree to comply with all city and county PLUMBING ordinances and state laws relating to building construction, anti BOILER-COME(3 H.P.or 100,000 B.T.U.) 4.00 x hereby authorize representatives of this city to enter upon tea above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL s (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and exposes which pER T ISSU CE 3.00 CONST.TAX may in any way accrue against said City in consequence of the gran gof l p• nit MECH. O LI . ? TorAHL TOTAL SiRllJ fApplican rtrac or Uatc ir/CT �� OFFICE COPY