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11032 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTI FIC PERMIT NUMBER APPLICATION $! PEIDT B°"°'"° 11032 r AODRESS .rl ��C�� Aw� UILDING-ELECTRICAL-PLUMBING-MECHANICAL OWNER'S PLAN CHECK VALIDATION NAME QTY ELECTRIC PERMIT FEE wAisoa PHDNF CONTRACTOR'S NAME UTLETS-SWITCHES-RECEP 10.00/1.00 ''''//''aF..�� q We- x /x/! /E� Ue.Nor ..�./. LIGHTING FIXTURES 10.00/1,00 f,ONTRACTOR'S//J/�ST nL/� PPLIANCES-RESIDENTIAL 4.00 ADDRESS ra'rJ I� /ry /' � PHONE/ �(?-8 ILVa PANELS 10.00 DATE OF APPLICATION ARCHITECTPANELS (OVER 200 AMP( 20.00 PLAN CHECK FEE P.C.NO. °R ENGINEER LIC.No. SIGNS TRANS. 3.00 io BREss ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP EMP.METER OR POLE INS. 20.00 APPLICANT'S IMOTORS SEE FEE S.C.H. ADDRESSSERVICE CHANGE 7 O w -.5 o LICENSED CONTRACTORS DECLARATION ID �/� /�A Q I hereby affirm that I am licensed under provisions of Chapter 9 A UANCE DATE I- z i (commencing with ction 7000)of Division 3 of the Business and BCD CT. PLG. MECH, F N z Professions Code my license is in lull for'a�n Iy(v�� 2 a, a w - License Class Lic.Numbers ❑ ❑ ❑ C, - Date Contractor_ i .f��/sN a y IRM PERMIT ¢ o w¢ OWNER-BUILDER DECLARATION INFORMATION odD MISC.- REFER TO ORD Z: ; a I hereby affirm that I am exempt from the Contractor's License VALUATION H U. o j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 Code:Any city or county which requiresapermit to construct,alleq W 2 ¢<0 improve ,demolish,or repair any structure,prior to its issuance,SEES ELEC.CONTR. LIC.NO. FLEE. / requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO w$m he is licensed pursuant to the provisions of the Contractor's License r+�/ U� Fi > La..(Chapter 9(commencing with'Seclion 7000)of Division 3 of the SK f� �T ¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢=$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. a. by any applicant for a permit Subjects the applicantloacivil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars($5000: ❑ 1,as owner of the property,Sr my employees with wages as BACK FLOW PROTECT.DEVICE 4,00 OCC.GROUP 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 of property who builds or improves(hereon,and who does such well FIXTURES-PER TRAP 5.00 56 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 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 of proving that he did not build or im- RES IND CON PB Other prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed SS contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 AESSORS 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 iLAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a contracloos)licensed pursuant to lire Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 - TRACT NO. PARCEL NO. ❑ lam exempt under Sec..,BAP.C.for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. ' WORKF.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified 1 copy thereof(Sec.3800,Lab.C.). ' / Policy No. Company 0-7L O Cenlrtlfied copy is hereby furnished. FIRE SPRINK ENERGY T-24 $�Cerlified copy is filed with the city myon 'vision. MISC.- REFER TO ORD. ❑ ❑ [:] ❑ pills V N Y N an -� PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C. CC 1 CERTIFICATE OF EXEMPTION FROM WORKERS' IL _ COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLC. Y❑ N❑ v❑ NE]1 Q (This section need not be completed it the permit is for one TOTAL D Z hundred dollars IS 100)or Ie i.) U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued,I shall not employ any person in any manner w as to O W become subject to the Workers Compensation Laws of California. a ALTER OR ADD TO MECH. 5.00 BUILDING Q. DateApplicant 3d f } N NOTICE.TO APPLICANT: If,after making this Certificate of Ex. ♦- ? emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK Z provisions of the Labor Code, you must forthwith comply with FEE L.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOAOOC.F.M.) 6.00 SEISMIC FEE 1 hereby affirm that there is a construction lending agency I'or EXHAUST HOOD (WITH DUCT) 5.00 the performance of the work for which this permit is issued(Sec. MICROFILM 3097,Cw.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00 information is correct.1 agree to comply with all city and county PLUMBING ordinances and state laws relating to building construction, and BOILER-COUP(3 H.P.or 100,000 B.T.U.) 6.00 hereby authorize representatives of this City to enter upon the BOILER-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 CONST.TAX may in e y way accrue ugaisst said City in consequence of the PERMIT ISSUANCE 10.00 grantin t i9 permit. MECH.CONT. LIC.NO. MECH. 3 V TOTAL TOTAL s �L Signature of App' nt/Contractor Dale OFFICE COPY