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3456 (2).* 0 O Z Z CC N Lu W _ ao U0 LL -U 0 N A APPLICANT TO'FILL IN INFORMATION WITHIN RED -LINES:- USE BALI- POINT PEN ONLY E BUILDING PROJECT I DENTI FICATION-' 4UILOING - ,. APPLICATION & PERMIT PERMITNUMBER •ADORE$$ ) 66 So UEANz4 SLI/2% _ "" G BUILDIN- ELECTRICAL'- PLUMBING -'MECHANICAL ' PLAN CHECK VALIDATION DATE OF APPLICATION OWNER'S NAMµE�/I� M�/� P/]p %�T` 8Arlrl PRPP P_r IC u PHONE QTY. ELECTRIC PERMIT FEE CONTRACTORS NAME `- •,> OUTLETS - SWITCHES -RECEP 5.00/1.00 LIGHTING FIXTURES- 5.00/1.00 CONTRACTORS 1 Ae 9Y� ADDRESS Al ✓r'7j]E]GG�I�L,I�'1 /y3'G �/ 5r/iLuA E /�/ ���/ PPLIANCES- RESIDENTIAL 4.00 PANELS 5.00 ARCHITECTC E/,//J DR 1'"�' �;�� ,x.4'337 ENGINEER uc. No. SIGNS6.00 PLAN CHECK FEE P.C. NO. •' ' r SIGNS TRANS.3.00 ARCH, OR ENG. - ADDRESS SPECIAL CIRCUIT 5.00 PERMIT VALIDATION TEMP. METER OR POLE INS. 15.00 ZIP , APPLICANT'$MOTORS._ ADDRESS .• SEE FEE SCH. SERVICE CHANGE - 10.00 LICENSED CONTRACTORS DECLARATION - - 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Profeae 0n4'Ode=nJ-m' license Is m toll fOICC' n =f eC� License Cla s S Lic. Nmnb r ISSUANCE DATE BLDG. ❑ ELECT. PLG'. MECH.' ❑ ❑ , Dale Contrado - u ' BUILDING PERMIT OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law forthe following reason. (Sec. 7031.5, Business and Professions Code', Any city Dreamily which requires a permit to construct, alter,, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractor's License' INFORMATION MISC:- REFER TO ORD - VALUATION--T$/FT. _ PERMIT ISSUANCE 6.00 ELEC. CONTE. LIC. NO. ELEC. TOTAL PERMIT TO OTY. PLUMBING PERMIT FEE Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and Lt, d STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a perout subjects the applicant ma civil penalty of not more than five hundred dollar (5500).)'. •ALTER -DRAIN & VENT -WATER (EA.)4.00 ❑ I, as owner of the property, or my employees with wages as sole compensation, will do the work, and the structure is not BACK FLOW PROTECT. DEVICE 2.00 Occ. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 4.00 intended or offered for sale (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 does such work himself or through his own employees, provided that such improve- menta are not intended or offered for sale. If, however, the building - FIXTURES - PER TRAP 4.00 SO. FT FLOOR AREA - - TOTAL ACREAGE - GAS - EA. 'SYSTEM -1 INC.4 OUTLETS 4,00 Por improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or in,RES prove for purpose ofsale.)' ❑ 1, as owner of the property, am exclusively contracting with licensed contractors 1. 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 GAS-- EA. SYSTEM -OVER 4 (EA.) 1.00 BUILDING USE IND CON PR Omer ❑ ❑ ❑ 0.0 INDUSTRIALWASTE INTER. 20.00 - ' LAWN SPRINKLERS ^1 INC 5 V.B. 5.00 ' S OG LAWN SPRINKLERS' -'OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. ' contracts for such projects with a contractors) licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT NO. PARCEL NO. El 'I am exempt under Sec. ,B.&P.C. for this reason WATER HEATER W/VENT 4.00 Dine Owner WATER SYSTEM 4.00 ACC. DATE ACL. FILE NO, WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP.' 4.00 1 hereby affirm that 1 have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance, or a certified - ZONING ENG. SITE NO. copy thereof Se . 0, Lab.C.). Polley No ompany ❑ Certified copy is hereby formal Certifle is Ble wit a city inspection division. pplicant - 1 FIRE SPRINK V ❑ IN E] ENERGY T-44 Y ❑ IN 1:1 M ISC.- REFER TO ORD. � CE. RTI F I CATE O F Ii XEM PTION F ROM WO R K Ii RS' PERMIT ISSUANCE6.00, FLOOD ZONE A.L.U.C. PLG.CONTR. LIC. NO. PLG. �7 TOTAL iv0 COMPENSATION INSURANCE (This section need not be completed if the peunil is for one • Y ❑ N ❑ Y ❑ N❑ hundred dollars IS 100) 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 DTV. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of California. ' Date ApplicantALTER NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption, you should become subject to the Workers' Compensation OR ADD TO MECH. 4.00 , APPLIANCE 4.00 PLAN CHECK ' provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked FEE. AIR HANDLING UNIT (TO 10MC.F.M.) 3.00 AIR HANDLING UNIT(OVER 10=0C.F.M,) 5.00 SEISMICFEE CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 - the performance of the work for which this permit Is issued (See. - 3097, Civ C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 4.00 HEATI NGUN IT (OV, E R 100,000 B.T. U.)7.50 ELECTRIC 'Lender' Lender'sxAddress - I certify that I have read this application and stain that the abuseVENTILATION information is correct. 1 agree to comply with all city and County ordinances and state laws relating to building construction, and FAN (SINGLE) 3.00 PLUMBING / O� BOILER-COMP(3 H.P. or 100,000 B.T.0-) 4.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes, MISC. - REFER TO ORD. CONST. TAX - ., •• (We) agree to save, Indemnify and keep ,harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consque ce f the PERMIT ISSUANCE 3.00 grantin of this permit y� n2��j2c /d L 7iy w �_T /I 8�� MECH. CONT. LIC. NO. MECH. TOTAL -��/'©V TOTAL Signature of Appli ant/Contractor Date .• OFFICE COP`! 7