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11960 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER nUILDI... , APPLICATION & PERMIT 11960 AODRess�/ 3 Al a) FE D ' �(( BUILDING - ELECTRICAL-PLUMBING-MECHANICAL OWNER'S / N PLAN CHECK VALIDATION �/All�P �E OTV. ELECTRIC PERMIT FEE CONTRACTORS �, UTLETS-SWITCHES-RECEP 10.00/1.00 T NAM q+ 0*,J D�L. LIc.No. LIGHTING FIXTURES 10.00/1.00 CONTRACTOR V) �W PPLIANCES-RESIDENTIAL 4.00 ADVRE s 07 6 &)NMrD P E 91of8/�� PANELS 6.00 DATE OF APPLICATION ARCHITECT PA NELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO. OR '� + /' ENGINEERW�f.LIIo-EErL. tJ0Al l No. SIGNS TRANS. 3.00 ARCH.OR ENGJ/ .. /q,T •�Y IO SPECIAL CIRCUIT 5,06 PERMIT VALIDATION ADDRESS JW © (./}/)0 6/¢. ZIP 14617- EMP.METER OR POLE INS. 20.00 APPLICANT'S MOTORS SEE FEE ADDRESS SERVICE CHANGE - 0.00 /.� woo LICENSED CONTRACTORS DECLARATION y ID /1// ¢u w I hereby affirm that I am licensed under provisions of Chapter 9 p ISSUANCE DATE wZ w (commencing with Section 7000)of Division 3 of the Business and ]`1n BLDG. ELECT. PLG. MECH. F w z Pocifessions Code,and my license is in full force and effect. t L ❑ ❑ z o m- License Clam-$�Lic.Number CI o F u. Date_(0=/.¢-BA Cu uniefor-Ifo-&- P BUILDING PERMIT ¢ w a OWNER-BUILDER DECLARATION INFORMATION K 3 u y I hereby affirm tam exempt that I t from the Contractor's License MISC.- REFER TO ORD a_ Law forthe following reason.(See.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION Code:Any cilyorcounty which requires atiermit to Construct,alter, 2 w¢¢2 improve,demolish,or repair any structure,prior to its issunce,also ELEC.GDNTR. LIC.NO. ELEC. 0 LL requires the applicant for such penult to file a signed statement that TOTAL �C� PERMIT TO A w m be is licensed pursuant to the provisions of the Contractor's License HZi Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe r i 4 o Business and Professions Code)or that he isexempt therefrom and CITY. PLUMBING PERMIT FEE ¢ r$ the basis for the alleged exemption.Any violation of Section 7031.5 qGROUP YPE CONSTR. u 3 - of any appnot licant five permit dsubjects rs the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 ❑ 1,as owner of the properly,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 ;OCC. 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 ofproperly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 TAL ACREAGE • himselfor through his own employees,provided that such improve- mentsam not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-1 6.00 or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE builder will have the burden 0f proving that he did not build or im- RES IND CON PB Other prove for purpose of sale.). INDUSTR IAL WASTE INTER. 30.00 ❑ 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPARCEL NO. and Professions Code:The Contractors 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.200 .00 TRACT NO, PARCEL NO. the Contractor's License Law. ❑ I am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent losel Ginsure, ZONING ENG.SITE NO. I or a certificate of Workers'Compensation Insurance,or a certified �}- copy thercof(Sec.3800,Lab.CJ. /+ Policy No. Company Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24 Z Z {�,Certife copy is filed with the City iy�pectioon division. MISC.- REFER TO ORD. � o H Applicant - lFw1 T _L.U.6L _ Y N V N cc - CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C. LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.TOTAL Y N� Y � NE) CL Q (This section need not be completed if the permit is for one ::) Z hundred dollars(8100)or IessJ U O 1 certify that in the performance of the work for which this per-Provisionsode, you must forthwith comply with AIR HNDLING UNIT(TO 1O=QF.NL) 4.00 FEE (.J N such provisions or this permit shall be deemed revoked. > t CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10= .F.M.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 MICROFILM the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 3097,Civ.CU. Lender's Name HEATING UNIT AMC(OV ER 100,000 B.T.U.19.50 ELECTRIC Q Lender's Address I certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00 PLUMBING information is correct.1 agree to comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00 ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property 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 PERMIT ISSUANCE 10.1 CONST.TAX may in any ay accrue against said City in consequence of the nhogo lhls pen 1. MECH.CONT. LIC.NO. MECH. TOTAL TOTAL Signature of Applicant/Contractor Data OFFICE COPY