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12378 (2)APPLICANT TO FILL IN INFOALATION WITHIN RED LINES - USE BSL POINT PEN ONLY - BUI LD1 NG PROJECT I DENTI FICA APPLICATION & PE e T BUI LDI NG - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 12378 aUILDING D Q ADDREaa S-/oa S --G o OWNEP'S NAMEptl1/WG�}-G?F'F GC%Q,BE" PHONE _ OTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION CONTRACTOfl'S NAME UTLETS - SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10,00/1,00 0 IC.No. .ONTRACTOR., DDRES4„ ^� APPLIANCES- RESIDENTIAL 4.00 PANELS 10,00 v DATEOF APPLICATION ARCHITECT OR ENGINEER LIC. NO. �sPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ARCH,OR ENG. ADDRESS SPECIAL CIRCUIT 5. PERMIT VALI DATION TEMP. METER OR POLE INS. 20.00 MOTORS SEE FE - ZIP avvucaers ADDRESS LICENSED CONTRACTORS DECLARATION /I J ,r Ino �/ / SERVICE CHANGE .00 � ofCup 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the business and Professions Cod�N�d y license: is in full for`pt[Cy License Classsjjj Lic. Number [)areContractorJ. Contractor 9, ISSUAN E DATE BLDG. ELECT. PLG. MECH. DING PERMIT BUILORMATION OWNIR-BUILDER DECL ION I hereby affirm that I am exempt from a inc,samor's License Law for th¢ity following reason. (h requires a permit tocnd Professions iode: Any city or county which requirese permit to construct, alter, improve, demolish, or repair any structure, prim 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 Law (Chapter 9(commencing with Section 7000) of0ivision 3 of the Business and Professions Code) or that he is exempt therefrom and INFORMATION MISC.- REFER TO ORD VALUATION -PERMIT ISSUANCE 10.00 /D- EL C. CONTR. LIC, NO. ELEC. �P TOTAL' /5 L/ PERMIT TO ���� r L OTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of5ection 7031.5 ALTER -DRAIN IEA.) 5.00 by any applicant for o permit subjects the applicant to a civil penalty of not more than five hundred dollars (8500).): ❑ 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 and Professions BACK FLOW PROTECT. DEVICE 4,00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, 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 that such improve' ments are not intended or offered for sale. If, however, the building _ FIXTURES - PER TRAP 5.00 SEE FT. FLOOR AREA TOTAL ACREAGE GAS-EA.SVSTEM-1 INC.40UTLETS 6.00 or Improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or im- prove for purpose of sale.). ❑ 1, as owner of the property, am exclusively contracting with GAS • EA. SYSTEM - OVER 4 IEA. 2.00 BUILDING USE RES IND CON PB Omer ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INT 30.00 licensed contractors to 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 LAWN SPRINKLERS- 1 INC 5 V.B. 0 LAWN SPRINKLERS - Ef1.) ,00 ASSESSORS PARCEL NO. contracts for such projects with a contractor(s) licensed pursuant to the Contractors License Law. SEWER-SANITAR V -S EA. 200ft/ TRACT NO. PARCEL NO. ❑ I am exempt under Sec. ,B.&P.C. for this reason WATER HEATER W/VE .00 Owner Date WATER SYSTEM 5.00 v,}'O' ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 WORK ERS'COMPENSATION DECLARATION 1 hereby affirm that 1 have a certircate of consent m self -insure, or a certificate of Workers' Com pen5ytion Insu crgp e, or a certified copy thereof (Sec. 3800 Lab.C. ZONING ENG. SITE NO. Policy N2 Co FIRE gPRINK v❑ N❑ ENERGY T-24 v❑ N❑ tl��y-/�y[�✓�g'„`��/ ❑ Certified copy is. fi hereby meshed. i Certified o y is fl i 'ify ins b n division. pplu: MISC.- REFER TO ORD. CE RTIFICATF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10-00[/0 FLOOD ZONE AL.U.C. CON ENSATION INSURANCE (This section need not be completed if the permit is for one P .Co TR,L .NO. PLG. TOTAL v ❑ N❑ Y [:] N❑ hundred dollars ($100) of less.) 1 certify that in the performance of the work for which this per mil is issued, I shallnot employ any person in any manner so as to QTY. MECHANICA ERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 APPLIANCE5.00 AIR HANDLING UNIT IT F.M.) 4.00 PLAN CHECK FEE emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT( OVER 10,000 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, CN.C.). - EXHAUST HOOD IW iI 5.00 MICROFILM HEATING UNIT IT ,00013 T % 0 H EAT[ NG U N IT(OV E .U.)9.50 • - ELECTRIC Lender's Lender's Address Address VENTILATION FAN (SI GCE) 4.00 I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and PLUMBING / BOILER•COMPI30.0r lOO,0008.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. (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 asequence of the grming oft ls r it. �q� PERMIT ISSUANCE 10.00 0 - CONST. TAX MECH. CONT. LIC. NO. MECH. TOTAL S1 y&&'C'R, _ w��v � �.%� TOTAL / Goo Signatu o' pplicanl/Contractor ale OFFICE COPY