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8930 (2)• LY APPLICANT TO FILL IN INFORMATION WITHIN LINES - USE BALL POINT PEN ONLY BU I LDING PROJECT I DENTIFICATI ON APPLICATION & PERMIT BUILDING -ELECTRICAL -PLUMBING -MECHANICAL . PERMIT NUMBER 8930 BUILDING ADDRESS 7_3 d A- N; err -Y-t, PTY. ELECTRIC PERMIT ,FEE, PLAN CHECK VALIDATION DATE OF APPLICATION CONTRACTOR 5 NA''E/ . 7111elis, LIC,NGL:XyS00 OUTLETS -SWITCHES- RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 CONTRACTORS ADDRESS APPLIANCES -RESIDENTIAL 4.00 PANELS 10.00 ARCHITECT OR ENGINEER LIC. NO. PANELS (OVER 200 AMP) 20.00 PLAN CHECK F7 P.C. NO, SIGNS TRANS. 3.00 ARCH. DR ENG. ADDRESS ZIP SPECIAL CIRCUIT 5.00 PERMIJ_VALIOATION APR TEMP. METER 08 POLE INS. 20.00 APPLICANT S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 7 1986 CII.. of LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code y license is in full force t�o/ License Lic. Number A cupepo ISSUANCE DAT BLDG. ELECT. MECH. El E3 El Date Contractor OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law forthe followingreason, (See, 7031.5. Business and ProfessionsPERMIT Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance. also requires the applicant for such permit to File a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 ofthe Business and Professions Code) or that he is exempt therefrom, and the basis for'he alleged exemption. Any violation of Section 703 1.5 by any applicant fora permit subjects the applicant to a civil Penalty of not more than five hundred dollars (5500).): n --'KB ILDINRMIT.-,%,-ji� ATIONI­ A. -R, MISC. - REFER TO ORD ISSUANCE 10.00 VALUATION ELEC. CONTR. LIC. NO. ELEC. TOTAL PERMI QTY. PERMIT_.`�, ,.FEE ST IES TYPE CONSTR. ALTER -DRAIN & VENT -WATER (EA.) 5.00 0 1, as owner of the property, or my employees with wages as their Sale compensation, will do the work, and the Structure is not BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREq COND. 5.00 intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law don not apply to an owner of FIXTURES - PER TRAP 5.00 GAS - EA. SYSTEM - 1 INC. 4 OUTLETS 6.00 •QC 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 prove" I'M 0 mems not intended or offered for .1.. If. however, the Irpldi`.`Ig" or Improvement is mid within one year of completion, the owner. It builder will ... the burden of proving that he did not build or im. GAS � EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE prove far purpose of Sale.). Cl 1, as owner of the property, am exclusively contracting with IND CON PB OHIH., a 0 D El 1:1 INDUSTRIAL WASTE INTER. 30.00 ' LAWN SPRINKLERS. 1 INC 5 V.S. 6.00 LAWN SPRINKLERS -OVER 5 (EA.) 1.00 licensed Contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who ASSESSORS PARCEL No. contracts for such projects with a contraclor( a) licensed pursuant to the Contractor's License Law. 0 lam exempt under Sec. . BAP.C. for this mason SEWER -SANITARY -STORM EA. 200ft/I 0.00 TRACT NO.. PARCEL NO. WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACG DATE ACC. FILE NO. I WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 lhe y affirm that I have a certificate of consent to self -insure. or a c lificate of Workers' Compensation Insurance, or a certified op hireof (Sec. 3800. Lab.C.). cy No..Company- ZONING ENG. SITE NO. FIRE SPRINK NE] ENERGY T 24 Y [3 N[] "i C y rlified copy is h Peby f rushed, .s4 c ed it file 411h it It r Applicant 401 . ..... Applicant MISC. REFER T R R I T OF 'EM TIFICATE OF EXEMPTION FROM WO& E LANCE PERMIT ISS 10.00 FLOODZONE A.4.1).C. COMPENSATION INSURANCE (This section need not be completed if the permit is for one ❑ N CD Y ❑ N Cj PLG. CONTR. LIC. NO. PLG.V TOTA I/ hundred dollars IS I DO) 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 OTY. _I,, IMECHANICAILPFRMIT FEE ✓ 'FEE SUMMARY,".- BUILDING become subject to the WorkerCompensation Laws of California. Dam Applicant NOTICE TO APPLICANT: If, after making this Certificate or Es. ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 AIR HANDLING UNIT (TO 10,000C F.M.) 4.00 PLAN CHECK FEE emption, you Should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued ISce. 3097, Civ.C.). EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address H EAT] NG UN IT (OVE R 100,000 B.T.U.) 9.50 ELECTRIC I certify that I 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 Ordinances and state laws relating to building construction. and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. PLUMBING BOILER- COMP(3 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP lova, 100,000 BTU) SEE FEE BCH. MECHANICAL (We) agree to Save, indemnify and keep harmless the City of Cupertino against liabilities, judgments. costs and expenses which may in any ecc against said City in consequence of the "y' MISC. - REFER TO ORD. CONST. TAX PERMIT ISSUANCE 10.0F alm 'this p Me �11 MECH CONT LIC. NO. MECH. TOTAL .;1To-rAU_- -.- 7.., rihi m IAPI iTem, Dare OFFICE COPY