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11313 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT 1 DENTI FICATION PERMIT NUMBER D . APPLICATION & PERMIT A11313 ADDRESS BUILDING - ELECTRICAL-PLUMBING-MECHANICAL OWNER'SPLAN CHECK VALIDATION NAME CITY. ELECTRIC PERMIT FEE .PHONEuKb-IG 13 CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00 6NOME (,�. c��-7 91car uc.No. OJIIa LIGHTING FIXTURES 10.00/1.00 CONTRACTOR s APPLIANCES-RESIDENTIAL 4.00 ADDRESS ((1111 II rVi ONEgL1I,0-(Cl CS PANELS 10.00 DATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. OR O ENGINEER LIC.NO. - SIGNS TRANS. 3.00 A.C..ss ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP TEMP. METER OR POLE INS. 20.00 / ADDFEES MOTORS SEE FEE SCH0.00 ADDRESS SERVICE CHANGE 20.00 0 o LICENSED CONTRACTORS DECLARATION <v w I hereby affirm that I am licensed under provisions of Chapter') ISSUANCE DATE z (commencing with Section 7000)of Division 3 of the Business and Ci¢ BLDG. ELECT. PLG. MECH. H so z Professions Co and my license is in full fora n 0 i H W Licen CIB Lie.Number ❑ ❑ ❑ Date Contractor P YBUILDING PERMIT ¢ 0 a O OWNER-BUILDER DECLARATION _ INFORMATION X ; LL H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VA ATION $/FT. u0¢ Law for the following reason.(Sec.7031.5,Businessandl'rofessions PERMIT ISSUANCE - 10.00 0 Cade:Any city orcounty which requires a permit to construct,alter, re W ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. dDLL requires the applicant for such perrrlll to File a signed Statement that TOTAL PERMIT TO E m m he is licensed pursuant to the provisions of the Contractor's License Hi> law(Chapter 9(commencing with Section 7000)of Division 3 ofthe ,O D ¢ Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE It rc r o the basis I'ar the alleged exemption.Any violation of Section 7031.5 ----STORIES TYPE CONS R. d ; �2 by any applicant for a permit subjects the applicant oa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 of not more than five hundred dollars($500).1: ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCG 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,COND. 5.00 \ Code:The Contractor's License Law does not apply to an owner of J property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE himself re through his own employees,for sale.Provided Ihat such impnrve- himssarunolinghhis oroempld ees,provided that s the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00 or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 200 builder will have the burden of proving that he did not build or in'. - . - . . BUILDING USE prove for purpose ofsale.),pe. RES IND CON PB Other INDUSTRIAL WASTE INTER. 30.00 El ❑ El 11 1:1❑ I,as owner of the property,tun exclusively contracting with licensed 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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft110.00 the Contractors License Law. TRACT NO. PARCEL NO. ❑ lameaemptunder Sec. ,BAP.C.Rrtl is WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKGRS'COMPIiNSATIONDf:CLARATION WATER TREATING EQUIP. 5.00 " I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0. or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Set.3800.Lab.CJ.'.vC Cd/' Policy No. Company W F `� - Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24 Z Z Certifin coy n fled with the city inspection division. ❑ ❑ ❑ ❑ O A p icxmC7C MISC.- REFER TO ORD. v N v N H r2 PERMIT ISSUANCE 10.00 LU CERTIFICATE POF ENEXEMPTION NSUR(1MWORKf:RS' FLOOD ZONE a.L.U.C. IL CO ed not a Com INSURANCE the PLG.CONTR. LIC.NO. PLG. Y❑ IN Y ❑ 1 O (Tris section need not be completed if the permit is for one TOTAL N ::) Z hundred dollars($100)or less) U O 1 certify that in the performance of the work for which this per-' OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL U mit is issued,I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California. UJ Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING ` } W 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 U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 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 tl(is termit is issued(Sec. MICROFILM 3097,Ch,C.L ^/� A' HEATING UNIT(TO 100,000 B.T.U.) 6.00 Lender's Name1V1� HEATING UNIT(OVER 100,000 B.T.U.)9.50 Lender's Address�T+L.._gt1��K r 1 ELECTRIC /. I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 1 information is correct.I agree to comply with all city and county -PLUMBING / ordinances and state laws relating to building construction, !anti[ BOILER-OOMP(3 H.P.or 100,000B.T.U.) 6.00 hereby authorize representatives of this city to enter upon theaboveBOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL / hereby authorize property Itativor inspectionr this 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 10.001CONST.TAX may in any way accrue,against said City in consequence of the rantin of this errn' G MECH.CONT. LIC.NO. TOTAL TOTAL - Signatureof p Team/Comrnctor Date OFFICE COPY