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10261 (2)�,,,JAPPL I CANT TO FILLqM INFORP4ATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJEC 1[ANTI FICA T N APPLICATION &PERMIT BUILDING -ELECTRICAL- PLUMBING -MECHANICAL PERMIT NUMBER 10261 ppoq, � OwNER's NAME OTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION PHONE NON Acr R' UTLETS- SWITCHES -RECEP 10.00/1.00 LIC, NO, LIGHTING FIXTURES 10.00/1.00 OooaR s AS APPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 PHONE DATE OF APPLICATION ORRC ITEC ENGINEER LIC, NO, PANELS (OVER 200 AMP) 20,007`7 LAN CHECK FEE P.C. NO, SIGNS TRANS. 3.00 ARCH ENc, ADD ZIP SPECIAL CIRCUIT 5.00 PERMIT VALIDATION PAID MAR 2 p �9C76 TEMP. METER OR POLE INS. 20.00 APDL 's ADD MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CON'T'RACTORS 11ECLARATION TEMP. POLE 30.00 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Businessd Professions LP my license is in full fort - LicensaClus. Lic. Number {�� { p k'., CltysAfAG fto BLDG. ELECT. PLG. I ECM Date Contractor BUILDING PERMIT INFORMATION OWNER -BUILDER DECLARATI Contractor's License 1 hereby affirm that I am exempt tram the Business Law for the followingreason.(Sec.7031.5,ermit tocnd Professions Code: Any city or county which requires a permit to consuanc alter, improve, demolish, or repair any structure, prior 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 MISC. - REFER TO ORD PERMIT ISSUANCE 10.00 VALUATION $/FT. ELEC. CONTR. LIC. N0. ELEC. TOTAL P gMIT TO Law (Chapter 9 (commencing with Section is7000) Division3 the and Business and Professions Come) or that lie is exempt therefrom end exempt CITY. PLUMBING PERMIT FEE the basis for the alleged exemption. Any violation of Section 7031.5 i by any applicant for a permit subjects the applicant loo civil penalty of not more than five hundred dollars ( $500).1: STORIES TYPE CONSTR. ALTER -DRAIN & VENT -WATER (EA.) 5.00 O I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00 intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of FIXTURES - PER TRAP 5.00 property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve. meats are not intended or offered for sale. If, however, the building 9Q. FT. FLOOR AREA TOTAL ACREAGE GAS - EA. SYSTEM - I INC.4 OUTLETS 6.00 or improvement is sold within one year of completion, the owner- builder will have the It of proving that he did not build or im prove for purpose Of sale.). ❑ I, as owner of the properly, am exclusively contracting with - . -. GAS EASYSTEM OVER 4 IEA) 2.00 BUILDING USE E IND CON PB Other C] ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS -OVER 5 (EA.) 1.00 licensed contractors to construct the project (See. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of properly who builds or improves thereon, and who I ASSESSORS PARCEL NO. contracts for such projects with a conlractoAs) licensed pursuant to the Contractor's License Law. ❑ Tam exempt under Sec.-, B &P.C, for this reason SEWER -SANITARY -STORM EA. 200ft/10,00 TRACT N0. PARCEL N0. WATER HEATER W/VENT 6.00 Owner Dale WATER SYSTEM 5.00 Act. DATE ACC. FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate of consent to sell' -insure, ZONING ENG. SITE NO. or a certificate of Workers' Compensation Imu ice, Or a cert ied copy there C.). Policy N ny, .p/CerWie copyi eby for ertificJ co rs IkJ III inspcc Uon Division. phcant FIRE BPRINK Y� N� ENERGY T 2 V� N� MISC.- REFER TO ORD. .PERMIT ISSUANCE 10.00 CER OF Ii PTION FROM WORKERS' OMPENSATION INSURANCE This section need not be completed if the permit is I'or one FLOOD ZONE Y ❑ NC] A.L.U.C. Y E] N� PLG. CONTR. LIC. NO. PLG. TOTAL hundred dollars (S 100) or less.) 1 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 to QTY. MECHANICAL PERMIT 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 APPLIANCE 5.00 AIR HANDLING UNIT (TO 10,000CF.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=C.F.M.) 6.00 JEJISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 the performance of the work for which this permit is issued (Sec. 3097, Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00 CROFILM Lender's Name Lender's Na mress' H EATI NG U N IT (OV ER 100,000 B.T.U.) 9.50 TRIC VENTILATION FAN (SINGLE) 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 hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. PLUMBING BOILER- COMP 13 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100.000 BTU) SEE FEE BCH. MECHANICAL (We) agree it save, i nify and keep harmless the City of Cupertino ago' liabif es judgments, costs and expenses which ma any y ac a gains[ said City in,c�snsequence of the mi of is per MISC. - REFER TO ORD. PERMIT ISSUANCE 10.00 ONST. TAX M CONT. LIC. NO. MECH. 4 1Z f p ican on a for I)ate TOTA TOTAL �) OFFICE COPY F