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8258APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 8258 BUILDING ADORES tI5a yO9wrBrxN4+���EH'S �rI �.�ppQ� (�v /-10-as CITY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION 1 `^^ HONE NCONTERACTORs A\I f'"1a)Wn& uC.No.0iJ0.7?tJ UTLETS- SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1,00 raN REss TOR 3811 - - O IARCHITECT PPLIANCES-RESIDENTIAL 4.00 PANELS 10.00 PHDN DATE OF APPLICATION OR ENGINEER LIC.NO. PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C. NO. SIGNS TRANS.3.00 ADDRESSs ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION TEMP. METER OR POLE INS. 20.00 ZIP G I APPLICANT'S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 ��" LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions CodyC�nd m 'enec is in full f Licer4!-T I:pfs..,� Num e ISSUANCE DATE BLDG. ELECT. I PLG. I MECH. 1:1 ❑ o Date , 1 C-1i^i otracto Contract. BUILDING PERMIT INFORMATION OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law( A the Aldol orcountywhiche.uires a permit town Professions Code: Any city or county which mquiture permit to construct, , also improve, demolish, or repair any structure, prior n its issuance, also requires the applicant for such permit ns file a signed statement that he is licensed 9(copursuant to the provisions of the Contractor% License Law (Chapter 9(commencingwith Section is exempt therefrom Business and Professions Code) or that he is exempt therefrom end and MISC.- REFER TO ORD PERMIT ISSUANCE 10.00 VALUATION S/FT. ELEC. CONTR. LIC. NO. ELEC. TOTAL PERM TO r DTV. PLUMBING PERMIT FEE STORIES TYPE CONSTR. the basisfor the allegedexemption. Any violation t to action malty by any more fora hundred 0).): am toecivil penalty of not more than five h dollars ($500).): prop dollars (my ALTER -DRAIN BE VENT -WATER (EA.) 5.00 ❑ I, as owner of the property, or my employeeswith wages as e emp their sole compensation, will do the work, and the structure Is not BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00 intended or of(ered,far sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of FIXTURES - PER TRAP 5.00 GAS - EA. SYSTEM -11 NC.4 OUTLETS 6.00 SO. FT, FLOOR AREA TOTAL ACREAGE property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- ments are not intended oroffered for sale. If, however, the building 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- GAS - EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE prove for purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with RES IND CON FB Omar INDUSTRIAL WASTE INTER. 30.00 licensed contractors to construct the project (Sec. 7044, BusinessLAWN and Professions Code: The Contractor's License Law does not apply to an owner of properly who builds or improves thereon. and who SPRINKLERS- 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 IEA.) 1.00 ASSESSORS PARCEL NO. contracts for Such projects with a contractorts) licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec.., B.&P.C. for this reason SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC. DATE ACC, FILE NO. WORKS RS'COMPENSAI' ION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate ofconsent to self -insure. or a Certificate of Workers Compensation In prance, or a ratified ZONING ENG. SITE N0. Copy lh r e Q�Is�'C PolicY dhlpuhy ❑ edified copy is hereby furnished. Certir� y. is�LS•tLsgiW�tlse Lv'IIy inspection Aivuion. Applicum _T_ =71'}` 111 FIRE SPRINK Yo N(] ENERGY T-24 y [] N MISC. - REFER TO ORD. CERTI FI CAI'E OF FXEMPITON I' ROM WOR K Ii RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. COMPENSATION INSURANCE (This section need not be completed if the permit is for one PLG. CONTR. LIC. NO. PLG. TOTAL Y ❑ N Y C] N hundred dollars IS 100) or less.) I certify that in the performance of the work for which this per mit is issued, I shall not employ any person in any manner So as to QTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of California. Date ApplicantALTER OR ADD TO MECH. 5.00 NOTICE TO APPLICANT: If, after making this Certificate of lix- APPLIANCE 5.00 - PLANCHECK FEE emption, you should become subject to the Wnrkers'Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT (TO 10=C,F.NQ 4.00 AIR HANDLING UNIT (OVER 101MC-F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 the performance of the work for which this permit is issued (Sec. 3097, Ci,C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Names HEATING UNIT (OVER 1 00,000 B.T.U.) ELECTRIC VENTILATION FAN (SINGLE) 4.00 I certify that I have read this application and state that the above information is correct. 1 agree to comply with all city and county ordinances and state laws relating to building construction, and PLUMBING BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL 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 MISC. - R E ORD. Cupertino against liabilities, judgments, vests and expenses which may in any way accrue against said City in consequence of the r off is pen lit on S' lure of Applicant Ctracto a c PERMIT ISSUANCE 10.00 CONST. TAX M1E�H. CONT. LIC. NO. MECH. TOTAL I VA11 iilY TOTAL V V J OFFICE COPY