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C 5703 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY, BUILDING PROJECT IDENTIFICATION - APPLICATION & PERMIT' BUILDING - ELECTRICAL- PLUMBING - MECHANICAL yEyMIT NUMB ER- `-� 5703 In O noue ss`' I (� OWNER S NAME CLU QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION L_ PHONE clalRs NAME NAME UTLETS- SWITCHES -RECEP 5.00/1.00 LIGHTING FIXTURES 5.00/1.00 LIc. No. , :orvrRAcK.Rs AooREu PPLIANCES- RESIDENTIAL 4.00 5.00 '•27 ONEPANELS DATE OF APPLICATION ARCHITECT OR ENGINEER I .No. SIGNS 6.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 An CH.ORENG. AooREss SPECIALCIRCUIT 5.00 PERMIT VALI DATION EMP. METER OR POLE INS. 15.00 ZIP APPLICANTS ADDRESS 2,- j MOTORS SEE FEE SCR. SERVICE CHANGE 10.00 LICENSED CONTRACTORS DECLARATION - I hereby affirm that Iain licensed under provisions of Chapter 9 ISSUANCE DATE (commencing with Section 7000) of Division 3 of the Bo,iness and Professions CO� 4f my liccn.0 is In lull force and 11�C},. � Licane ClassoltA- _ LiC. Number�op ` ^ _' _ V �- B DG. ELECT. ❑ PLG. MECH. ❑ ❑ ��r� �'{;rl.S]-�_ Uatc Contractor ...sm, . BUI LDI NG�PERMIT OWNIi R -If UI LIJIiR DECLARATION that I aexempt from the Contractor's License I hereby affirm m Law for the followingreason.(See 7031.5. Husinessand Professions Code: Any city or commy which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also INFORMATION' .; MISCREFER ORD .- VALUATION E/FT. PERMIT ISSUANCE 6.00 ELEC. CONTR. LIC. NO. ELEG requires the applicant for such permit 10 file a signed statement that he is licensed pursuant to the provisions of the Contractor's License 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 the basis for the alleged exemption. Any violation ofSeetion 7031.5 STORIES TYPE CONSTR. ALTER -DRAIN & VENT -WATER (EA.) 4.00 by any applicant for a permitsubjects the applicant to a civil penalty of not more than five hundred dollars (S5000: ❑ [,as owner of the property, or my employees with wages asggCK their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions FLOW PROTECT. DEVICE 2.00 OCC. GROUP RES. UNIT DRAINS -FLOOR, ROOF, AREA, COND. 4.00 Code: The Contractor's License Law docs not apply In an owner 0f property who builds or improves thereon, and who does such work F IXTUR ES - PER TRAP 4.00 So. FT. FLOOR AREA TOTAL ACREAGE himself or through his own employees, provided that such improve- mcuts are not intended proffered for sale. If. however, the building GAS - EA. SYSTEM - I INC.4 OUTLETS 4.00 Or notoOvemalt is sold within one year of completion, the Owner- builder will he IIIc burden of Invoing that he did not build or im- av prove for purpose of sale.). ❑ I, as owner of the property, am ex0miively'Contracting with licensed Contractors if, construct the project (Sc. 7044, Business GAS - EA. SYSTEM - OVER 4 (EA.) 1.00 BUILDING USE IND CON PB Omer ❑ ❑ ❑ ❑ ASSESSORS PARCEL NO. INDUSTRIALWASTE INTER. 20.00 LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 and Professions Code: The Contractors 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 contractor(s) licensed pursuant to on, Contractor's License L.W. SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT No. PARCEL No. WATER HEATER W/VENT 4.00 ❑ lam exempt under sec. .B.&P.C. 1'or this Ravin Owner Urate WATER SYSTEM 4.00 ACC. -DATE ACC. FILE NO. WORK ERS'COMPI?NSA'f10N DECLARATION WATER TREATING EQUIP. 4.00 I hereby affirm that I have a certificate of consent to self -insure. or a certifie lc of Workers' Compensation Insurance, Or a certified ZONING ENG. SITE NO. copy there 1 S•'. 0 Lab .1. rarer Nn.y2�ib) 3 SidEeEfF I ao FIRE SPRINK, ENERGY .24 ❑ Ce,fir. JcupY nv here livnishul. x Certif• cop s file w'th t CiI inspection Division. I 'Plica nt_1C,gCATI NS16��{Z$1RONI .Ty Y ❑ N❑ Y ❑ INC] MISC. - REFER TO ORD. PERMIT ISSUANCE 6.00 FLOOD zoNF A.L.u.c. CER'1'I PICATIi OP F:FIinIPI'I(lN 1'ROnI W/U�RKERS' PLG. CONTR, LIC. NO. PLG. TOTAL COMPFNSATION INSURANCE $This section need not be Completed if file permit is for one v E] ry ❑ v ❑ N ❑ OTY. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars (S 1001 or less.) 1 certify That in the performance Of Ile work for which this per- mit is issued, I shall not employ any person in any manner so as to G hcmmc subject to the Workers' Compensation Laws of California. , Dame Applicant ALTER OR ADD TO MECH. 4.00 NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption. you should become subject to the Workeri Compensation provisions of the tabor Code, you must forthwith comply with such provisions or this permit,hull be deemed revoked. APPLIANCE 4.00 ECK LE AIR HANDLING UNIT (TO I0X0C.F.fvL) 3.00 AIR HANDLING UNIT (OVER IO,000C.F.M.)5.00 FEE CONSTRUCTION LENDING AGENCY EXHAUST HOOD (WITH DUCT) 2.00 HEATING UNIT (TO 100,000 B.T.U.) 4.00LM f hereby affirm tlml there is aconstruction lending agency for the performance of the work for which this permit is issued (Sec. 3097, CIv.C.). ' HEATING UNIT (OVER 100,000 B.T.U.)7.50 ELECTRIC Lender's Name Lender, Address 1 certify that I have read this application and state that the above inl'ontmtion is correct. 1 agree to Comply with all city and county ordinances and state laws relating to building construction, and VENTILATION FAN (SINGLE) 3.00 PLUMBING BOILER-COMP(3H.P.or-100,000B.T.U.) 4.00 BOILER -COMP (OYer 100,000 BTU) SEE FEE SCH. MECHANICAL hereby authorize representatives of this city to enter upon the uboveamentioned 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 aid City in consequence of the PERMIT ISSUANCE 3.00 MECH. CONT. LIC. NO. MECH.' OTAL TOTAL $0 grantingofthis permit , I 3&11R Si aturc of Applicant/Conlragor Ute OFFICECOPY