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11347E O ZZ H v0 -i 0 W_ CL D Z UO_ LL I- 0 w U • APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECTIDENTIFICATION APPLICATION & PERMIT BUILDING -ELECTRICAL- PLUMBING -MECHANICAL PERMIT NUMBER 11347 BUILDING � ADOREBB - I O V5 _USI-�`t�1l.1(QZ ZOa OWNER'S NAE 1\1 OTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION JQiAA ) PHONE , DATE OF APPLICATION NOMER4CT0 s (,.;e -}1y ay� 12EMt Oklrl CLC'L I�IC uc.N t. icb (i UTLETS-SWITCHES-RECEP 10.00/1.0 LIGHTING FIXTURES 10.00/1.00 CONTRACTORS ADIDREcss J y _ v, ,y b �� I' kk%x4 a PHONE 2 boll t L i APPLIANCES - RESIDENTIAL 4.00 PANELS 10.00 ARCHITECTPANELS OR �1 ENCINEE/T H Lni IV 2 I; ke LIC NO (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. ISIGNS TRANS. 3.00 AENG. ADDDDRR. ESS ss SPECIAL CIRCUIT 5.00 PERM _ ION TEMP. METER OR POLE INS. 20.00 ZIP XJ 2 i n�1p (JOU �C/ty Of CwnQrso ln APPLICANTS ADDRESS t `� .7 UlCb�p4A GaAwoig- J1jry .)01� MOTORS SEE FEE SCH. - SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect License Class Lia Number BLDG. ❑ ELECT. .n/ L PLG. MECH. ❑ ❑ Date Contractor BUILDING PERMIT OWNER -BUILDER DECLARATION I hereby affirm that I ng so exempt from the Contractor's License Law for the or countywhichn. c. INFORMATION MISC. - REFER TO ORD VALUATION SIFT. PERMIT ISSUANCE 10.00 WCOdProfessions ity requires a permitloco issuanc Bite. Code: Any miry or county which struitesap prior prior m its issuance, also improve, demolish, or repair any permit requires the applicant for such permit to lite a signed statement that to file he is licensed pursuant to the provisions of the Contractors License ELEC. CONTR, LIC. NO. ELEC. TOTAL 9E MIT TO OTY. PLUMBING PERMIT r FEE Law, (Chapter 9 (commencing with Section 7000)o(Division 3 of the Busness and Professions Code) or that he is exempt therefrom and IO,•/vC/�/. STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5 ALTER -DRAIN & VENT -WATER (EA.) 5.00 by any applicant for a permit subjects the applicant 10 a civil penalty of rat more than five hundred dollars (S500).)'. ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work. and the structure is not BACK F LOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA,COND. 5.00 intended or offered for sale (Sec. 7044, Business and Professions 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 5.00 SD. FT. FLOOR AREA TOTAL ACREAGE himself or through his own employees, provided that such improve ments are not intended ar offered for sale. If, however, the building GAS - EA. SYSTEM - 1 INCA OUTLETS 6.00 or improvement is sold within one year of completion, the owner builder will have the burden of proving that he did not build or im- 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 Law does not apply t0 an owner of property who builds or improves thereon. and who GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 euILDIN SE � RES IND 0 PB Omer � INDUSTRIAL WASTE INTER. 30.00 LAWN SPR INKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS A CEL NO. contracts In, such projects with a contractons) licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL N0. Cl I am exempt under Sec.-. B &P.C. fur this reason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC. DATE ACD. FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that 1 have a certificate of consent m self -insure. or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy thereo((Sec. 3800, Lab.C.). Policy No, Company ❑ Certifiedcopy isherebyfurnished. ❑ Certified copy is tiled with the city inspection division. Applicant FIRE SPRINK Y ❑ N ENERGY T24 Y D N[3 MISC. - REFER TO ORD. CF.RTIFICATF,OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u, C. PLG. CONTR. LIC. NO. PLG. TOTAL COMPENSATION INSURANCE (This section need not be completed if the permit is for one Y D IN Y ❑ NE] - - OTY:,,. MECHANICAL PERMIT FEE , FEE SUMMARY hundred dollars IS 100) or less.) I certify that in the performance of the work for which this per- mit is issued, shall not empll any erson navy man In so as to become ec the Workers np ti Laws o Ca' omia. Date Applicant NOTICE O APPLICANT: If, a t making this Certificate of Ex- BUILDING ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 PLAN CHECK emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FEE AIR HANDLING UNIT (TO 10=C.F.M.) 4.00 AIR HANDLING UNITIOVER 10=C.EM.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sem. 3097, Civ.CJ. HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATING UNIT IOV ER 100,000 B.T.U.) 9.50 ELECTRIC Lender's Name Lender's Address VENTILATION FAN (SINGLE) 4.00 PLUMBING 1 certify that I have read this application and state that the above information is Correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and BOILER -COMP (3 H.P. Or 100,000 B.T.U.) 6.00 BOILER -COMP (Over tOO,000BTU) SEE FEE SCH. MECHANICAL hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes, (We) agree to s ve, indemnify a Ikeep harmless the City of CupertinR agairet b bilines, 1 men sJ costs and expenses which ma in ny way a rue aAay�.tr-s,Wt^said Qity in consequence o th gean n�1�QL'his per \I \ b 1) 4 . 11'..N,1QVW `, w\I r! � MISC. - REFER TO ORD. CONST. TAX PERMIT ISSUANCE 10.00 ECN. CONT. LIC. N0. MECH. TOTAL TOTAL Saint of Applicant Onfmclot Date OFFICE COPY