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4948 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER aDILDING APPLICATION & PERMIT 4948 FDDRESss��..-- x ; 7✓1-� BUILDING-ELECTRICAL-PLUMBING -MECHANICAL OWNER'5 q � / PLAN CHECK VALIDATION NAME > e+'tiJpal--7 1 7 0TY. ELECTRIC PERMIT FEE J /✓ I S PRONE ONTR4CTOR'S N / UTLETS-SWITCHES-RECEP 5.00/1.00 LIGHTING FIXTURES 5.00/1.00 rorvrRAcrors A DOREss - PPL.IANCES-RESIDENTIAL 4.00 PHONE '� PANELS 5.00 DATE OF APPLICATION ARCHITECT PLAN CHECK FEE P.C.NO. OR SIGNS 6.00 ENGINEER uc.No. SIGNS TRANS. 3.00 ARCH OR ADDRESS ENG. SPECIAL CIRCUIT Fj.DD PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 15.00 ADDRESS ADDRESS MOTORS SEE FEE SCH. S ��VL....�. -- SERVICE CHANGE 10.00 13111 o o LICENSED CONTRACTORS DECLARATION /13 j 1J G ,U 1 hereby affirm that I am licensed under provisions ofCWplCr 9 ISSUANCE DATE H a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. F o z Professions Cod tf y,license is in full force a effec - ❑ ❑ ❑ z O vs - Licen-S, Sss_ 'an Lie Number Z 9 w r w Date Com rector_ a x M BUILDING PERMIT ¢ ¢ w a OWNER-BUILDER DECLARATION E D a INFORMATION X g act I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD F Ia Oa Law for the following reason.(See.7031.5,Busincssand Professions PERMIT ISSUANCE 6.00 VALUATION q/FT. Code:Any city or county which reyuiresa permit to construct,alter. ¢ ¢< 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. - D LL requires the applicant for such permit to file a signed statement that TOTAL e w Co he is licensed pursuant to the provisions of the Contractor's License - PERMIT TO F z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe PLUMB/n/�].. 4 o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE ¢ .m by any applicant for a permit subjects the applicant too civil penally the basis for the alleged enemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. La3 _ of not more than five hundred dollars(5500).1. ALTER-DRAIN& VENT-WATER (EA.) 4.00 ❑ I,as owner of the property,or my employees with wage's as BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP RES.urvti5 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,CON D. 4.00 Code:'Thu Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 so.FT FLOOR AREA TOTAL ACREAGE -. himself or through his own enployccs.Provided that such imProve- memsarenotintendedorofferedl'or sale.IL however.the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00 t or improvemmnt is sold within one year of completion.the owner- builder will have the burden of proving that he did not build Or im- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON Pe Goner ❑ I,as owner of the property,an exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors to construct the project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. and Professions Code:The Contractor's License Law docs not apply to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1,00 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. ❑ lamcxemptundcr Sec. ,B.&P.Cti+r this reason WATER HEATER W/VENT 4.00 Date Owner WATER SYSTEM 4.00 ACC.DATE ACG.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATINGIEtiAto 4.00 ' I hereby off m tour I have a certificate of consent to self-insure, or a certificate of Workers Com Pensjltion Insurance.or a certified �J ZONING - ENG.SITE NO. copy IhcRRf(Sea 3800.Lab C.1. ��..ff rrpp d Policy No. ConspanyoAll:F- �� O ❑ Certiliedcopy is hereby famished FIRE SPRINK ENERGY T24 Z Z ❑ Certify copy is filed will] the city n ection division. TOO L F Cl Applicant '��•/r/�� MISC:.. I }` Of [;O fl� ❑ ❑ ❑ ❑ _ N V N CERTIFICATE OP EXF%IPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.0 hI . LU � COPENSATION I NSURANCE PLG.CONTR. ;TO . PLG. d 0 IT his section need not be completed if the permit is for one TOTAL/v '� V❑ N❑ Y ❑ N❑ Z) Z hundred dollars IS 100)or less.) U O 1 certify that in the performance of the work for which this per- CITY. EOR PERMIT FEE FEE SUMMARY LL U mil is issued,I shall not employ any person in any manner so as to O w become subject to the Workers'Compensation Laws of California. C. Dam Applicant ALTECH. 4.00 BUILDING } to NOTICE TO APPLICANT: If,after making this Certificate of Ex- emption,you should hosome subject to lire Workers'Compesation APPL4.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE such provisions or this permit shall be deeomd revoked AIR H10=C.F.M.) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE 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 IS, MICROFILM 3097,Civ.C.L HEATING UNIT (TO 100,000 B.T.U.) 4.00 Lender's Name Leaders Address HEATI NG UNIT(OVER 100,000 S.T.U.)7.50 ELECTRIC I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 information is correct. 1 agree to comply with all city and,county PLUMBING I ordinances and state haws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 Q hereby authorise representatives of this city to enter upon the gDILER-COMP (Over 100,000 BTU)SEE FEE SCH. above-mentioned property for inspection purposes. MECHANICAL (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 any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00 g tingof his FCrailt. - f MECH.CONT. LIC.NO. MECH. G �•L L C2sG' ' /� TOTnL TOTAL igna re of Applicant) 'ontructor at OFFICE COPY