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6624 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 'BUILDING PR JECT IDENTIFICATION PERMIT NUMBER 1 aU,DAEss APPLICATION & PERMIT s S 5 )Uj BUILDING-ELECTRICAL-PLUMBING-MECHANICAL -6624 OWNER'S �uLy �r„y.7r.! - Q` fA "*N� ' `.� el {y"h M1 P ,,� ,� PLAN CHECK VALIDATION NAME FF''y 'DIrJ H.�.+ CITY S '4 1-WI m4glV/Q _5-fw 7V ELECTRIC PERMIT : S EE-:4 NAME AcrORs UTLETS-SWITCHES RECEP 5.00/1.00 R{G'�Os YV�D / G Llc.uo. LIGHTING FIXTURES ' 5.00/1.00 " CONTRACTORS �pe-ra�ia�y /� APPLIANCES-RESIDENTIAL 4.00 - ADDRESS hD�� N f.D. PHONE S�-L; PANELS 5.00 DATE OF APPLICATION ARRC HITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO. ENGINEER . LIC.NO. - SIGNS TRANS. 3.00 ADDRiSSS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP EMP.METER OR POLE INS. 15.00 ADMOTORS SEE FEE SCH. ADDRESS ORES$ SERVICE CHANGE 10.00 ,00 0o LICENSED CONTRACTORS DECLARATION a v 1 hereby affirm Ihm 1 am licensed under provisions of Chaplet 9 ISSUANCE DATE (commencing with Section 7000)of Division 3 of the Business and Q y BLDG. ELECT. PLG. MECH. H N Z Professions Cod}}.•.,an,I,my license is in full f rte and effect. - 2 o m- License Class.[r{�_Lie.Numb ❑ e©.t' 8 2 r w Dnro_{.,J.r.1i_�Collr: f 'A �,,` a la J - CX� �`:';BUILDING PERMIT ¢ ¢w OWNER-BUILDER Ec 170 ,INFORMATION w ; LL I- I hereby alflrm that I am exempt from the Contraetur's License MISC.- REFER TO ORD ' AM-' 1--- LL o to Law for the following reason,(Sec.703L5,Business and Professions VALUATION $/FT. _ g PERMIT ISSUANCE,' 6.00 Grade:Any city or county which structure permit to usfir ,Beq yL�✓x.(r`[ p ¢ ¢ et 0 improve,Demolish,or repair any structure,prior no its issuance,also ELEC.CONTR. LIC.NO. ELEC. / 01 CUpe� IUB ca O LL' requires the applicant for such permit to file a signed statemem thm TOTAL n w m he Is licensed pursuant to the provisions of the Contractor's License PERMIT TO J ClZ F z a Law(Chapter 9(commentingwnh Section 7000)of Division 3 ofthe k.2.* ��E S �iNXG.GI�s i O Business and Vmficvsmns Code)ar that he is exempt lhnrefrom and QTY': "y, sx ,,y ,PLUMBING,PERMIT=.' FEE?' ¢ H$ the balls for the alleged exemption.Any violation of Seel ton 7031.5 -,I-., STORIES TYPE CONSTR. a ; _ by any applicant for a permit subjects the applicant to acivil penalty ALTER-DRAIN -WATER (EA.) 4.00 - of not morn than five hundred dollars($500).): ❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.ceouP REB.UNITS their sole compensation,will do the work,and the structure Is not intendedbr offered for Sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 Code:Tile 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 4.0D 50.FT.FLOOR AREA TOTAL ACREAGE , himself or through his own employees,provided that such improve. meets are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4,00 or improvement is sold within ane year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1,00 - BUILDING USE builder will have the burden of proving that he did not build or im prove 1.as o RES IND CON PB Other of sale.). h . 20.00 0 0 0 0 0 ❑ '1,as ownernee of the property,am exclusively contracting with INDUSTRIAL WASTE INTER licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-i INC 5 V.B. 5.00 ASSESSORS PARCEL NO. and Professions Code:The Contractor's License Lew does not apply to an owner of property who builds or improves lhercon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for Such prajeetx with a contractors)licensed pursuant to the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO. ❑ I am exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 4.00 reason Owner Date WATER SYSTEM 4.00 ACC.DATE ACC FILE NO. WORKF-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 I hereby affirm that I have a certificate of consent m self-insure, or a certificate of Workers'Compensation, n a cetlified ZONING ENG.SITE NO. copy lhcreoff .3 0 �irYtV�,7�� Policy Npfd1�I�If -/dr_,,,�a .�{./q Q CerhfieJ opyr Krchy urmshcd. r�>•r"'_' /e'' FIRE SPRINK ENERGY T-24 Z 'I]IQ Ctr" copy is f�pd wi 11 ' inspeclimr division. p}�. MISC.- REFER TO ORD. vE] N� v ❑ No c y CER1'1PICA'I'E 01'EXEMPTION PROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C. 'W COMPENSATION INSURANCE' PLG.CONTR. LIC.NO. PLG. j Z ('this Sectidn,need not be completed if the permit is for one TOTAL YE] . No V F] NE] hundred dollars($100)'or less.)' gdN.3 L IyY a' YV U O I certify that in the perfomhance of the work for which this per QTY .Ay .. ,„r,MECHANICAGP,EFIII ,y o'tR t, 4iFEE vFa"IEE SUMMARY LL I- mit Is issued,I shall not enhpluy any,person In any mummer So as to H II r, • y O w become subject to the Workers'Compensation Laws of Califorma. �JJJf, �. a Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING I } w NO'1'ICIi I'O AI'PhICAN'I': II,alter making Olin Certil irate of EA' E annidwo,yell should become subjeelao[be Workers Compensation APPLIANCE 4.00 PLAN CHECK provisions of the Labor.Code, you must forthwith comply with FEE -7 U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M.) 3.00 CONSTRUCTION'LEN DING AGENCY - AIR HANDLING UNIT(OVER 10p0OC.F.M.) 5.00 SEISMIC FEEfd 1 hereby affirm that [here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 the pc mu tr nc. of the work for which this permit is issued(Seo. MICROFILM 3097,CiJ,C.). r HEATING UNIT(TO 100,000 B.T.U.) 4.00 Leader's Address B.T.U.17.50 Lender's Namedre H EATING UNIT(OVER 100,000 ELECTRIC I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 Information is correct. I agree to comply with all city and county PLUMBING' ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 hereby authorize representatives of this city to enter upon the BOILER-COMP IOvnr 100,000 BTU15E_E FEE SCH, MECHANICAL above-mentioned properly for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Misc.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which CONST.TAX may m any N'aY :Item• against Said City in consequence of the PERMIT ISSUANCE 3.00 gnntin o> Ii1. Ni CONT. LIC.NO. MECH. TOTAL TOTAL ' 40 Signature$ignane of Applicant/Cants s char ole t OFFICE COPY