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11220 (2)0 0 a:z FOo QUU „ay O 0 f w u S oj H LL wy a ¢ 0 0 al S, nwm rZi f i o Icr $ O _Zz N LU W_ CL 7) z 00 LL U Oa F... z Z r APPLICANT TO FILL IN INFOLMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUI LDI NG PROJECT I DENTI FICAId APPLICATION & PE r BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 11220 ADDRESS Aoonlss y� / �o05 , Poe OWNER'S fJ p ri e S PHONE NjL OTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION - DATE OF APPLICATION CONTRACTORS NAME ,j / W16.S dl,, 1C -.!L LIC.No.7L, 1O UTLETS-SWITCHES-RECEP 10.0011,00 LIGHTING FIXTURES 10.00/1.00 ACONTRACTOR 's DRESS 1(072-I I LIC­6WhLAfl,* PHONE3SV-W1_? PPLIANCES- RESIDENTIAL 4.00 PANELS' 10.00 ARCHITECT -S CIEl OR ENGINEER LIC. NO. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 - ADDRESS esa. SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION EMP. METER OR POLE INS. 20.00 ZIP �J p ✓,�/� ACANTS ADDRESS ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTRACTORS DRCLARATION I I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cod • and, license is in full fore • od f� Y Y License las Lic. Number ISSUANCE ATE BLDG. ❑ ELECT. PLG. MECH. ❑ Dale Con[ruclor BUILDING PERMIT INFORMATION OWNER -BUILDER DECLARATION I hereby affirm that I um exempt from the Contractor's License Law fol -the l'ollowingreason.ISec. 7031.5, Business an IP...fiasioos Cade: Any city or county which requires a permit to Construct, atter, improve, delnolish,orreporony sIUMILIIC, priorto its issuance, also requires the applicant for such permit l0 file a signed statement that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and MISC. -' REFER TO ORD VALUATION $/FT. PERMIT ISSUANCE10.00 ELEC. CONTR. LIC. NO. ELEC. TOTAL PERMIT TO 1l (- OTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. the basis for lbe alleged exemption. Any violation of Section 7031.5 by any applicant fora permit subjects lhcapplicant too civil penally of not more than five hundred dollars ($5000.): ALTER -DRAIN -WATER IEA.) 5.00 ❑ I, 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 aad Professions BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS Z DRAINS -FLOOR, OOF AREA, COND. 5.00 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 [hat such improve- ments are not intended or offered for sale. If, however, the building FIXTURES - PER TRAP 5.00 50. FT, FLOOR AREA TOTAL ACREAGE GAS-EA.SYSTEM-11NC.40UTLETS 6.00 or improvement is sold within one year of completion, the owner- builder will have the burden of proving that h e did not build or im- prove for purpose of sale.), ❑ 1, as owner of the property, am exclusively contracting with GAS - EASYSTEM -OVER 4 (EA) 200 . .. BUILDING USE RES IND CON PB Other ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does nod apply to an owner of property who builds or improves [hereon, and who LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 D TRACT NO. PARCEL NO. ❑ lam exempt under Sec.-, BAP.C. for this 011 WATER HEATE T 6.00 Owner Date WATER SYSTE 5.00 ACC. GATE ACC. FILE NO. WATER TREAT GL OU(,y0, ' 5.00 WORKL'RS'COMPENSATION DECLARATION 1 hereby affirm that 1 have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance, ora cyrlified copy [hereof IS 800, I.A.C.), s� Policy No ompany 2 ❑ Certified copy is hereby furnished. ❑ Certi(ic copy is fled a the aty spection division. Applicant Qb, r� - n' •%� JUVA ZONING ENG. SITE NO. P 1 FIRE SPRINK Y ❑ N ❑ ENERGY T-24 Y ❑ N❑ MISC. - REFER TO ORD. CE RTI FICATI; OIe EXEMPT ION FROM WORK ERS' PERMIT ISSUANCE 10 -00/0 -FLOOD ZONE A.L.U.C. COMPENSATION INSURANCE section need, not be completed if the permit is for one PLG. CONTR. - LIC. NO. PLG. q ill)) TOTAL J J - Y N ❑ ❑ Y ❑ NE] hundred dollars ($100) or less.) I certify that in the performance of the work for which this per- Bit is issued, 1 shall not employ my person in any manner so as to OTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the'Workers' Compensation Laws Of California. . Date�APPlieant NOTICE TO APPLICANT: If, after making this Certificate of Ec- ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 AIR HANDLING UNIT (TO 10=C.F.M.) 4,00 - PLAN CHECK FEE emption, you should become subject to the Workorti Compensation provisions of the Labor Cade, you must forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT (OVER 10=C.EM.) 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. 3097, Civ.C.). 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 Lender's Name Lenders Address I certify that 1 have read this application and state that the aboveVENTILATION information is correct. 1 agree to comply with all city and County ordinances and stale laws relating to building construction, and hereby authorize representatives of this city Io enter upon he above-mentioned property for inspection purposes. FAN (SINGLE) 4.00 PLUMBING - BOILER -COMP 13 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL MISC. - REFER TO ORD. (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 mid City in consequence of the PERMIT ISSUANCE 10.00 CONST. TAX grant orbit iiermit. MECH. CONT. LIC. NO. MECH. (4 &-!� TOTAL TOTAL Signature of Applicant/Contractor )ate OFFICE COPY