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12007 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED.LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER G APPLICATION & PERMIT ADDRESS 2��7 AODREss 1043 Colon Hills BUILDING-ELECTRICAL-PLUMBING-MECHANICAL OWNER'S PLAN CHECK VALIDATION NAME ' OTY. ELECTRIC PERMIT FEE n Barbara DodsworthpHONE / -6GG CONTRACTORS NAME UTLETS-SWITCHES-RECEP 10.00/1.00 Atlas Heating LIC.No.4652z 6 LIGHTING FIXTURES 10.00/1.00 CONTRACTOR PPLIANCES-RESIDENTIAL 4.00 Yy ArDR5 Commercial St SHONE 739-0516 PANELS 10.00 DATE OF APPLICATION ARCHITECTPLAN CHECK FEE P.C.NO. OR PANELS (OVER 200 AMP) 20.00 ENGINEER _LIC.No. SIGNS TRANS. 3.00 AARCH.OR DDRESS ENO SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP EMP.METER OR POLE INS. 20.00 APPLICANTS MOTORS SEE FEE SCH. ADDRESS - _ SERVICE CHANGE 20.00 O w o o LICENSED CONTRACTORS DECLARATION 3 2 a u w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE H <a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELEOT. PLG. I MECH. F M i Profession Co Cly license is in to Beet, 2 o u� Licerrl�l Lia.Num tractor - ❑ ❑ ❑ 9 Z.r °m Dare Contractor a x s BUILDING PERMIT w4 OWNER-BUILDER D17CLARATION INFORMATION woA" MISC.- REFER TO ORD ; a H I hereby affirm that I am exempt from the Contractor's License VALUATION S/FT. F u o¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 Code:Any cityor county which requires a permit to construct,alter, ELEC.CONTH. LIC.NO. Q W¢ 0 improve,demolish,Or repair any structure,prior to its ISSIIJIIC¢,aI50 ELEC. n E C u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO E re he is licensed pursuant to the provisions of the Contractor's License Fir Law(Chapter 9(commencingwith Section 7000)ofDivision 3 ofthe a Business and Professions Code)or that he is exempt therefrom and OTY. 'PLUMBING PERMIT FEE re r$ the basis for the alleged exemption.Any violation of$ection 7031-$ STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS their sale 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 docs not apply to an owner of properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50,FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve GAS-EA.SVSTEM-11NC.40UTLETS 6.00 mems are not intended or offered for Sale.If,however,the building or tmprovemenl 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- HES IND CON PB Omer prove for purpose of sale,). INDUSTRIAL WASTE INTER. 30.00 ❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors to construct the project(Sea 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 contracts for such projects with a contractods)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00 the Contractors License Law. TRACT NO. PARCEL NO. ❑ I am 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. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 ' 1 hereby affirm that I have a certificate of Consent to self-insure, ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO. copy there fq f g15 ` 38QO,�ab.0 Policy No. « y l -p30e- Q ❑ C¢rtifie Copy is her yfumise FIRE SPRINK ENERGY T34 Z Z 01 C¢rtifi�PQLq gy Is Jed w'h the city inspection division. U ApplicantllPla, ea't MISC_ REFER TO ORD. v ❑ N❑ Y ❑ N❑ ~ In 0: CIiRTIFIC PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. - UJ >_ COMPE COMPEEXEMPTION FROM WORKWORKERS'NSATION INSURANCE PLG.CONTR. LIC.NO. PLG. CL 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ .Y ❑ N❑ D Z hundred dollars IS 100)or less.) L) O 1 certify that in the performance of the work For which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued, 1 shall not employ any person in any manner so as to U become subject to the Workers'Compensation Laws of California. i Date Applicant ALTER OR ADD TO MECH)-�% 5.00 BUILDING >_ to NOTICE TO APPLICANT: If,after making this Centicure of Ex- ? inception,you should become Subject to the Workers'Compensation APPLIANCE - 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply wit h • FEE (.0 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,1506C.F:M:) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO O.F,M.16.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WIT4iIDUCT)e11111V 5.00 the performance of the work for which this permit is issued(Sec. MICROFILM 3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 goo Lender's Name Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC I certify that 1 have read this application and state 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-COMPI3 H.P.Dr 100,000 B.T.U.) 6.00 �^l 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 Cupertino against liabilities,judgments, costs and expenses which CONST.TAX may in ny way accrue against said City in consequence of the PERM ISSUAN E .00 ` o gmntm of this permit. MECH.CONT LIC. M TOTAL ��:an P'�or � /c / TOTAL Signature of Applicant/Conlraclor Date (� ,QD OFFICE COPY