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13105 (2)• a¢i too QZu � Qn O oy'w H_H Q y ne J a w 0 w 3n H Fu U. J ne 40 ca 6 W matW H Ria R 1-o asa O Z z 0 W - W > CL 0 D 2 UO LL U Oa } N H z WE APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY OILDfNG PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER __-- 13105 aDIL ,NG ,t OWNER'S "A V-`� CITY. ELECTRIC PERMIT FEE PLAN LHECK VALIDATION M�/� / �r�� PHONE DATE OF APPLICATION CONTRACTOR'5 rvam�E�� is4e.l• Lt.. No.-r� UTLETS- SWITCHES -RECEP 10.00/1.00 + LIGHTING FIXTURES 10.00/1.00 5 CONTRACTOR'S C ADDRESS Zpz A6410PHONE 'APPLIANCES -RESIDENTIAL 4.00 3 PANELS 10.00 off- ARCHITECT OP ENGINEER LIC. No. PANELS (OVER 200 AMP) 20.00 �+ PLAN CHECK FEE P.C. NO. SIGNS TRANS, ADDRESS ENG. r^� �3p.00 SPECIAL CIRCUIT n '! J\y.O6 PERMIT VALIDATION rrEMP. METER OR POLE INS. • 4,P /1 AJ ,� ,...r �' ✓ 1 r gFr"uu// FFx./i" -- V V /� ��Y/ e APPLICANT'S. AOORC55 / b p2�0.010 MOTORS H §yl'JLLrrr. - SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION $A'II /' 3�0su- Z9 x+ 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) Of Division 3 Of the Business and Professions Code anlf my license is in full fore a d f LicensY Clay Z� Lic, Num. IS UANCE DAT BLDG. .❑ ELECT. PLG. I MECH. ❑ ElDale "i� GOIIIraClO BUILDI OWNER -BUILDER DECLARATION d Contractor's License ' I hereby aoilo Ihal I am exempt from the Business Law for the fo or ounuy n.ch req iresa permitlocnd Professions Code: Any city or county which requirese permit loconstruct, issuance, , also improve, demolish, or repair any structure, prior t0 its issuvnce, also requires IM1C applicant for such permit IO file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.$ INFORMATION INFORMATION MISC.- REFER TO ORD - VALUATION $/FT. ow PERMIT ISSUANCE 10.00 mow- ELE CON/TPI. /y LIC. NO. L - - /� /YL' . �U9 ALL ELEC. 0� TOTAL �7 PERMIT TO �� G OTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. ALTER -DRAIN & VENT -WATER IEA.) 5.00 by any applicant for a permit subjects the applicant tua civil penally of not more than live hundred dollars($500).1: ' ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00 Cade: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work F IXTUR ES - PER TRAP 5.00 SO. FT. FLOOR aPEA TOTAL ACREAGE himself or through his own employees, provided that such improve. meats are not intended or offered for sale. If, however, the building GAS-EA.SVSTEM-1 6.00 or improvement is sold within one year of completion, the owner- builder Will have the burden of proving that IIC did not build or int- prove lot purpose of sale.). ❑ I, as owner Of the properly, am exclusively contracting with licensed contractors 10 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.) 2.00 BUILDING USE RES IND CON PB Other ❑ ❑ ❑ ❑ ❑ INDUSTRIAL W ASTE INTER. 30.00 LAWN SPRINKLERS - 1 INC 6 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. contracts for such projects with a emmo etor(s) licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑ I am exempt under Sec,-, B,&P,C. for this rcaeon WATER HEATER W/VENT 6.00 Owner Date 5.00 WATER SYSTEM . ACC.OATE ACC. FILENO. I -WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent to sel Ginsure' or a certificate of Workers' Compensation Insurance• o a certified ZONING ENG. SITE N0. copy thereef(See. 3800. Lab .C.I Policy No. Company ZC,l FIRE SPRINK V N ❑ ❑ ENERGY T-24 N ❑ ❑ Certified copy is hereby furnished. A�c nt if / py,5 fi with �� c�y inspection division. vv MISC. - REFER TO ORD. PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C. CERTIFICATE OP EXEMPTION FROM WORKERS' PLG.CONTR. LIC. NO. PLG, TOTAL COMPENSATION INSURANCE section need not be completed it the permit Is for one YE] N❑ V❑ N[3(This DTV MECHANICAL PERMIT FEE FEE SUMMARY hundred dabox($100) or less.)' I certify that in the performance of the work for which this per- mil is issued, I shall not employ any person in any manner so as t0 BUILDING become subject to the Workers Compensation Laws of California. Date Applicant ALTER OR ADD TOMECH. ' 5'.00 NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption, you should became subject to the Workers' Compensation provisions of tire Labor Code, you most forthwith comply with such provisions or this permit shall be deemed revoked. APPLIANCE 5.00 PLAN CHECK FEE AIR HANDLING UNIT (TO 10=C.F.M.) 4.00 AIR HANDLING UNIT (OVER 10MC.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 (Sec. Lender's Name EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC �l Lender's Address 1 certify that I have read this application and state that the above information is correct. I agree to comply wish all city and county ordinances and state laws relating to building consfruetion• and VENTILATION FAN (SINGLE) 4.00 PLUMBING gO1LER-COMP13 H.P, or 100,000 B.T.U.) 6.00 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 ma any way accrue 'go} nsl said City in consequence of the PERMIT ISSUANCE 10.00 MECH. CONT. LIC. NO. MECH. TOTAL TOTAL g . gofthi a j�� -B7 Signature of Applicant/Contractor Date OFFICE COPY