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13471oat, z FOO QVU N2w as oL; ZN - o Y ¢QwQ U X 3 FU04 i aCIC QQo m y 6 W r i < sic Lag aim s 0 Z_z P N cc LU - ao Z) z 0 0 LL P- 0 6 } U PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTI FI ON APPLICATION & AIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 13471 ADORE LC+Z 7-7 SS OWNER'S NAME PHCNE�.V a � TY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION DATE OF APPLICATION CONT�N NAME c aR- NAME ` ,N1 0L C. No. _ OUTLETS - SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 CONTRACTOR'S rfgA^ 1 ADDRESS O �{ PRONF APPLIANCES - RESIDENTIAL 4.00 -- a PANELS 10.0 - AROHITCT OR N IN L .o PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ARCH, OR ENKE- ADDRESS Del LI a,.. N 6 I P .w/SP ECIALCIRCUIT 5.00 PERMIT VALIDATION 9/-/4/f 17 UU // ISSUANCE DATE �- EMP. METER OR POLE INS. 20.00 APPLI ADDRESS ' MOTORS SEE FEE SCH. -SERVICECHANGE 20.00 LICIiNSEU CONTRACTORS DECLARATIONr I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions CoA. anQ m license is in full fore d f Numh)rw..7J.�/'r Date Convac OWNER -BUILDER DE A t{'/oirTyk' ( A'MO 1 hereby affirm (hal I am exempt from tireMISC.- Contractor's License Law for the following reason. (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuunt to lire 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 the basis for the alleged exetnpton. Any violation of Section7031.5 by any applicant for a permit subjects the applicant toa civil penalty of not more than five hundred dollars (5500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do tire work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law docs 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 - Hunts are not intended oroffered for sale. If, however, the building Crimprovement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or am- prove for purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Low does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractors) licensed pursuant to the Contractor's License Law. ❑ lam excmpl under Sec. ,B.&P.C. for this reason , 1 �U r _ - BLDG. ❑ ELECT. PLG. MECH, ❑ ❑ p y V 01 p BUILDING PERMIT INFORMATION REFER TO ORD VALUATION $/FT. PERMIT ISSUANCE 10.00 Q+- ELEC. CONTR. LIC. NO. ELEC. TOTAL /S__(0PERMIT TO CITY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. ALTER -DRAIN -WATER (EA.) 5.00 BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AR EA, COND. 5.00 FIXTURES - PER TRAP 5.00 50. FT. FLOOR AREA TOTAL ACREAGE GAS-EA.SYSTEM-11NC.40UTLETS 6.00 GAS EASYSTEM 00 - . - OVER 4 (EA.) 2. BUILDING USE RES IND CON PB Omer ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT N0, PARCEL N0. WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 WORKERS'COMPENSAT10N DECLARATION 1 hereby affirm that I have a certificate of Consent to self -insure, or a certificate of Workers' Com �Gt,�qmcc. or a certified copythereof f Sec. 3800•ipm,) } Policy o. is here ny_ e edified copy is hereby fur1 Certi d c py I fi Gil wisp gt ivislon. ��-�4.(r/ CER A .'cSLMlei7 MWORKERS' COMPENSATION INSURANCE (This section need not be completed if tire permit is for one hundred dollars ($100) or less.) I certify that in the performance of tire work for which this Per- mit is issued, 1 shall not employ any person in any mummer so as to become subject to the Workers' Compensation Laws of California. Date Applicant ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 - ZONING ENG. SITE NO. FIRE SPRINK V ❑ N❑ ENERGY T-24 V ❑ IN E] MISC. - REFER TO ORD.Appllc:Int'A1X_Q' PERMIT ISSUANCE 10.00 FLOOD ZONE Y ❑ No A.L.U.C. Y ❑ N❑ PLG. CONTE, LIC. NO. PLO. TOTAL OTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING ALTER OR ADD TO MECH. 5.00 NOTICE TO APPLICANT: If, idler making this Certificate of I'x- emptier, you should become subject to the Workers' Compensation provisions of the Labor Code, you most forthwith comply with such provisions or this permit Strait be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance rfo C ince of the work for which this permit is issued (Sec. Lender's Name APPLIANCE 5.00 PLAN CHECK FEE AIR HANDLING UNIT (TO 10/1000F.M.) 4.00 AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00 SEISMIC FEE EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC Az 0`10Lender's Address I certify that I have read this application and slate that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and 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 Cupertino against liabilities, judgments, costs and expenses which may in any way accrue, against said City in consequence of the grand of this permit, A,d v.� $ VENTILATION FAN (SINGLE) 4.00 PLUMBING 130ILER-COMP(3H.P.or100,000B.T.U.) 6.00 BOILER -COMP (Over IOQ000BTU) SEE FEE SCH. MECHANICAL MISC. - REFER TO ORD. CONST. TAX PERMIT ISSUANCE 10.00 MECH. CONT. LIC. N0. MECH. TOTAL-` J I to of Applicant/Con ctor ate OFFICE COPY