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09997 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN.ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER IMILDING APPLICATION & PERMIT 7 5 59 09997 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL OWNERPLAN CHECK VALIDATION -) NAME ONE QTY. ELECTRIC PERMIT FEE J� NAMEnALTORS UTLETS-SWITCHES•RECEP 10.00/1.00 Ir� Llc.No. LIGHTING FIXTURES 10.00/1.00 Q CONTRACTOR ONTRA TORa SuN1Jy�l_ [APPLIANCES-RESIDENTIAL 4.00 117 PHONE - PANELS 10.00 GATE OF APPLICATION ORRCHITECi PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. ENGINEER LIC.NOF. SIGNS TRANS. 3.00 AARCH.OR DDRESS ENG. SPECIALCIRCUIT 5,00 PERMIT ),f SON ZIP '- EMP.METER OR POLE INS. 20.00 �u ADDRESS MOTORS SEE FEE SCH. NOV ADDRESS •' 1 1N�V 11 7 SERVICE CHANGE 20.00 Woo LICENSED CONTRACTORS DECLARATION ITEMP.POLE 38.00 City of Cupertino ¢i w I hereby affirm that 1 am licensed under Provisions of Chapter 9 ISSUANCE DATE w a y' (commencing with Section 7000)of Division 3 of the Business and IL, - @LOG. ELE T. P G C H H z Professions Co nd my license is in full fort J c. ❑ z.0 m o License Class Lie.Number 9 a,r a, Date_L�I_ Contractor a x s < �� 56 - BUILDING PERMIT ¢. a ¢ OWNER-BUILDER DECLARATION¢s v r INFORMATION W I- I hereby affirm that I am exempt from the Contractor s License MISC.- REFER T ORD w © _VALUATION S/FT. Fu0 J Law ferny citylorcountywhi Sec.70resape sinessand Professions PERMIT ISSUANCE 10.00 k w< Z Code: e,dem y or county my it any structure, u tune, prior to construct,alter, ¢ ¢ a O improve,demolish,or repair any struC(ure,prior t0 its issuance,a150 ELEC.DDNTR, LIC.NO. ELED. A. 0¢ requires the applicant for such permit to file a signed statement that TOTAL �pERMIT TO K m he is licensed pursuant to the provisions of the Contractor's License H z r Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe 3 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE 01 ¢h$ the basis for the alleged exemption.Any violation of Suction 7031.5 STORI 5 TYPE NSTR. dg by any applicant forapertnitsubjecis the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00 offer more than five hundred dollars(5500).): ❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.G OUP R NITS their sole compensation,will do the work,and(he structure is not intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONDI 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 FIXTURES-PER TRAP 5. 9G.FT.FLOOR AREA TOTALACREAGE • himselfents of through his ownemployees.Provideothatsuchimprove- himself o nor intended one ered for employees, moved that s the building GAS-EA.SVSTEM-I1NC.40UTLETS 6.00 or improvement is sold within one year of completion, • . - . . the owner- GAS EASYSTEM OVER 4 IEA) 200 BUILDING USE builder will have the burden of proving that he did not build or im- E IND CON PB Omer prove for purpose of sale.). INDUSTRIAL WASTE INTER. ,30.00 O 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 ASSESSORS PARCEL NO. and Professions Code.The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 canlmcis for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 the Contractor's License Law. TRACT NO. PARCEL NO. ❑ lumexemto under Sec. ,BAP.C.for,this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.GATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent to wif-insure. ZONING ENG.SITE N0. or a certificate of Workers'Compensation Insurance,or a certified copy thermf(Scc.3800,Lab.C.). Policy No. Company O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24 Z2 6�Certified copy is filed with the city inspection division. MISC.- REFER ORD. O Applicant Y ❑ N E] Y [3 NE]p: vaPERMIT ISSUANCE 10.00 LU - CERTIFICATE OF EXEMPTIONFROM WORKERS' PERMIT ZONE A.L.u.C. W >_ COMPENSATION INSURANCE PLG.CONTR. - LIC.NO. PLG. � CL 0 (This section need not be Completed if the permit is for one IOTA Y❑ N❑ Y❑ N❑ Z) Z hundred dollars(S 100)or less.) L) O 1 certify that in the performance of(he work for which this per. GTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued,I shall not employ any person in any manner so as to O Q become subject to the Workers'Compensution Laws of California. BUILDING n Durc Applicant - ALTER OR ADD TO MECH. 5.00 ' } 0 NOTICE. TO APPLICANT: If,after making this Certificate of Ex- coalition,you should become subject to the Workers'Compensation APPLIANCE 5,00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE U Such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10PMC.F.M.) 6.00 SEISMIC FEE 1 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(Sea MICROFILM 3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50 Lender's Address ELECTRIC I certify that l have read(his application and stale that the above VENTILATION FAN (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.or 100,000 B. .U.) 6.00 hereby authorize representatives of (his city to emer upon the B01 LEfl•COM (Over 00, W BTU) E FEE SCH. MECHANICAL above-mentioned properly for inspection purposes. (We) agree to Save, indemnify and keepharmless the City or. MISC. xIII F fro ORD. Cupertino against liabilities,judgments, costs andexpenses which PER ISSUAN 10.0041 7- CONST.TAX may in any way occme against said City in consequence of the granting of this pe 't. MEC .CONT. LIC.NO. MECH. r rn I I-I-�L' TOTA1 TOTAL Slgnomre of App¢a ontractor Unle OFFICE COPY .