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09861 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY + BUI LD1 NG PROJECT 1 DENTI FICATION _ PERMIT NUMBER BUILDING APPLICATION & PERMIT O n ADDRESS `�' 2 BUILDING-'ELECTRICAL-PLUMBING-MECHANICAL OWNER'S NAME PLAN CHECK VALIDATION . • ON OTV. ELECTRIC PERMIT FEE 91, ONTRACTORS NAME p I UTLETS-SWITCHES-RECEP 10A0/1.00 J(7� Com(-1!OG� I l uc.N¢CIb-o1-(tI I -73 LIGHTING FIXTURES 10.00/1.00 noo ESE rot's PPLIANCES-RESIDENTIAL 4.00 1- 6 ,6+ PHONE PANELS 10.00 OI J DATE OF APPLICATION ARCHITECT PLAN CHECK FEE P.C.NO. OR - _ PANELS (OVER 200 AMP) 20.00 ENGINEER LAC.No. ISIGNS TRANS. 3.00 ZRCH ADDRESS ENG. SPECIAL CIRCUIT ' sG r , 5.0014-,0 PERMIT VALIDgTION, zIP EMP.METER OR POLE INS. 20.00 MOTORS ' SEE FEE SCH. �U -n '��fT� SERVICE CHANGE 20.00 a w o a LICENSED CONTRACTORS DECLARATION TEMP.POLE - 30.00----.: Q o u I hereby affirm that 1 int licensed under provisions of Chopter9 ISSUANCE DATE y <w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. r z Professions Code,an , Iy license is in full,mre a td eIT 1. o f=o License Class p m.Numb v 1 r m r J Date l Contract., w _ OWNER-BUILDER DECLARATION BUILDING PERMIT w0 u m I hereby affirm that I am exempt from the Conlracror's License MISC.- 7- +. REFER TO ORD INFORMATION u o 4 Law for the following rcason,(Sec.7031.5,Businessland Professions VALUATION -$/FT. - - PERMIT ISSUANCE 10.00 ��^^ � .4 2 Code:Any city or wumy which Tenures permit to construct,alteq I O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC:N0. ELEC. - - O M requires the applicant for such permit to file a signed statement that n w m" he is licensed pursuant to the provisions of the Contractor's License lC 7 I TOTAL , - PERMIT TO rzi Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe EL EG7 f 4 o Business and Professions Code)or that he is exempt therefrom and TY. PLUMBING PERMIT -FEE ac s-$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. ,d ; � by any applicant ora permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as CK F LOW PROTECT:DEVICE - 4.00 Occ.GROUP RES.UNITS their Sale compensation,will do Ilse work,and dile Strtlnture is not intended or offered'for sale (Sec. 7044, Business and Professions DR INS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work FIXT RES-PER TRAP 5.00 sD.FT.FLOOR AREA TOTAL ACREAGE • himself or through his own employees.provided that such improve. .. , meats are not inter ended or offered for sale.If,howev ,tire . e building GAS-E SYSTEM-11NC.40UTLETS 6.00 or improvement is sold within one year of completion;the owner GAS-EA. VSTEM-OVER 4(EA.) 2.00 builder will have the burden of proving that he did not build or im- BUILDING USE prove for purpose ofsale.); INDUSTRIA WASTE INTER. 30.00 - RES IND CON PB Omar ❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ 0 ❑ licensed contractors to construct the project(Sec.7044,Business LAWN SPR IN ERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. t and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who LAWN SPRINKL RS-OVER 5(EA.) 1.00 - contracts for such projects with a contract.oto licensed pursuant to SEWER-SANITAR TORM EA200ft/10.00 the Contractor's License Law. . TRACT NO. PARCEL NO. ❑ [am exempt under Sec.,B.&P.C.for this reason WATER HEATER,W/ NT 6.00 Owner Date WATER SYSTEM xxx 5.00 ACC.OATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER'TREATING EOU0l 5.00 I hereby affirm that I have a certificate of consent to SelGinsum,'or a certificate of W$orrkers'Compensation Insurance,or a certified ZONING ENG.SITE NO. Poilcylre,NrN+' S0 35LAom Pang'),(IIG _'❑'//Certified copy is hereby furnished, FIRE SPRINK ENERGY T-24 Z'Z rC,rtificd�}��+y�Is� file�t1,,gqlib hy' �ity ns reef�+n division. F O Applican;Hfied ' a 'F'l'/11' L_ MISC. REFER TOD. ' Y E] No ' Y NQ N CERTIFICATEOF EXEMPTION FROM WORKERS' - PERMIT ISSUANCE -10.6Q, FLOODZONE A.L.U,C. W > COMPENSATION INSURANCE PLG.CONTR. LIC,NO, PLG, OL. o (This section need not be completed if the permit is I'or one TOTAL Y❑ N V❑ N❑ Z hundred dollars($100)or less') U 01 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY LL F- mit is issued,I shall not employ any person in any manner so as to Ow' be come subject to the Workers'Compensation Laws of C.li(nmia. y Date ApplicaBUILDINGnt ALTER OR ADD TO MECH. 5.00 } to NOTICE TO APPLICANT: If,after making this Certificate of Ex- Z emption,you should become subject to the Workers'Compensation pP LIANCE' 5.00 PLAN CHECK Provisions of the Labor Code, you most forthwith comply Witt, _ FEE " U' such'provisions or this permit shall be deemed Invoked, AI ANDLING UNIT(TO 10MCY.M.) 4,00 CONSTRUCTION LENDING AGENCY - AIRH DLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUS HOOD (WITH DUCT) 5.00 tiro performance ul'the work for which this per Is issued ISaa' Is MICROFILM 3097,Civ.C.). HEATING U T(TO 100,0001 B.T.U.) 8.00 - - Lender's Name Lender's Address HEATING UNI VER 100,000 B.T.U.)9.50 ELECTRIC I certify tlmt I have read this application andstate that the above VENTILATION FA (SINGLE) - 4.00 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.O 00,000 B.T.U.) 6.00 Incoby aullmrile representatives of this city t0 enter upon the BOILER-COMP(Over 100,0 BTUI SEE FEE SCH. MECHANICAL above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep Imnnless the City of MISC:- FER TO ORD. Cupertino against liabilities,judgments, costs and expenses which CONST.TAX may in any way 'ecru, agm st said City in consequence.1 tile PERMIT ISSUANCE - 10.00 granting or ia MECH.CONT. - LIC.NO.. MECH. D + TOTAL S auo Conractor e TOTAL OFFICE COPY "