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1890 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 'BUILDING PROJECT I DENTI FICATION - ' . PERMI ' Nu R BUILDING APPLICATION & PERMIT ADORESS �( s 7 BUILDINGO - ELECTRICAL-PLUMBING -MECHANICAL DWNER's PLAN CHECK VALIDATION NAME+4 �1 OTY. ELECTRIC PERMIT FEE Vhi Iti R der ;L5 17- %363 NaMERnuc.Dn's �/ y UTLETS-SWITCHES-.RECEP 5.00/1.00 .r K 8"Q / 6 ;N'V' C Lm.NO (1/ �U $ ILIGHTING FIXTURES 5.00/1.00 CONTRACTOR'SAPPLIANCES-RESIDENTIAL 4.00 ADDRESS r.rL�7 ✓�JyV,��A Q((� _ PHONE ,,J[ 'T Qf� PANELS 5.00 DATE OF APPLICATION ARCHITECTr PLAN CHECK FEE PQ NO. oR - aR;a..✓/h�� SIGNS 6.00 ENGINEER I uc.No • SIGNS TRANS. 3.00 AAACROR DDRESS ENG SPECIAL CIRCUIT - 5,00 PERMIT VALIDATION ZIP TEMP.METER OR'POLE INS. 15.00 APPLICANT s MOTORS SEE FEE SCH. ADDRESS DOREss //.. Ir Q(�S SERVICE CHANGE 10.00 E o LICENSED CO RACTORS DECLARATIONCITJ _ PERr�yl/ ¢ u u I hereby affirm that I am licensed under provisions of Chapter 9 - 'ISSUANCE DATE w ¢w (commencing with Section 7000)of Division 3 of the Business and BLDG- ELECT. PLG. MEGH. r N z Professions Code and-� license Is in full force t f e¢Lg. © ❑ ❑ '❑ Z, z m License Cla Co Number ((l1 -. , ,�H Uate Contractor a y s - n'ras •BUIL"DING PERMIT''',',' ¢ ¢ w ¢ OWNER-BUILDER DECLARATION - r*� <ia rINFURMATIONx''wvy U MISC.- O ORD w ;n a 1 hereby affirm That I am exempt from the Contractor's License VALUATIOPry� .. o'¢ Lawlor the following reason(Sec.7031.5,Business Professions PERMIT ISSUANCE 6.00 �y/ $/FT. r - Code.Any city or county which requires a permit to construct,alter,. `34&0 K Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC,CONTR. LIC.NO. ELEC. (J l/ , wO u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO $ he is licensed pursuant to the provisions of the Contractor's License �/J Hzr Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe _ /Y G:/Q.VO� �Ls• Business and Professions Code)or that he is exempt therefrom andQTV. , •- ' f LUMRING"PERMITT `. r - .FEES.," " ¢ H e the basis for the alleged exemption.Any violation of Section 7031.5 - - ,' ST RIFrg KTV E CONS R w. w- by any applicant for a permit subjects the applicant tracer]penalty ALTER-DRAIN IEA.I400 of not mora Ikon five hundred dollars(5500).)'. - ❑. I,as owner of the property,or my employee's with wages as BACKFLOW PROTECT. DEVICE 2.00 OCG GROUP RES,UNITS their sole compensation,will do the work,and the structure is not . .. intended or offered for Bale (Sec. 9044, Business and Professions Code: ROOF,AREA,CON D. 4.00 Code:The Contractor's License Law does not apply to an owner of property who builds or Improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SC.FT,FLOOR AREA TOTAL ACREAGE himself re through hi.......loyers,provided that such im building -cents are not intended oroffcfore Provided ed 11rdhowever,[hcbmlding GAS-EA.SYSTEM-1INC.4OUTLETS 4.00 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE builder will have the burden of proving that lie did not build or im RE5 IND CON PB Omer" . prove for purpose of sale.). INDUSTRIAL WASTE INTER. 2000 ❑ 1,as owner of the property,am exclusively contracting with � ❑ ED ❑ 0 licensed contractors to .mulct 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 does not who to tr owner of property s wi builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 contracts for such License projectswith a contractorfs)licensed pursuant to the Contractor's License Law.- SEWER-SANITARY-STORM EA.200ft/6.00 - TRACT NO. PARCEL NO. ❑-I am exempt under Sea,.,B&P.C.for this WATER HEATER W/VENT 4.00 reason Data Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO. WORKE-RS'COMPIENSAT10N DECLARATION WATER TREATING EQUIP, 4.00 I hereby affirm that I have a certificate of consent to self-insure, - or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO. copy Cher• c 00,LAIC). �,.� FU/vJ Policy No Company - O ❑ Certlfl�ls hereb famished. FIRE SPRINK ENERGYT"24 Z 2 ❑ Certifi r i ft mm, tl city inspection division. MISC.- REFER TO ORD. � O Appli c:mt _ A - v N v11 N Fps PERMIT ISSUANCE 6.00 LU 1 Cf:RTIPICCOM E SATI N ON FROM WORKERS' FLOOD ZONE A.L.U.C. . W > COMPENSATION INSURANCE PLG.CONTE. uc.No. PLc. CL CI( This section need not be completed if the permit is for one TOTAL V O'• -N� V N� hundred dollars IS 100)or less.) ,- , L) O 1 certify that in the performance of tete work for which I]'his per- CITY. - MECHANICAL PERMIT - .'FEE;' --FEE SUMMARY, ` LL F mit is issued,I shall not employ any person in any manner so as to Wbecome subject to the Workers'Compensation Laws of California. - - a Date Applicant ALTER OR ADD TO MECH. 4,00 BUILDING } w NOTICE TO APPLICANT: If,after making this Certificate of IIx- - Z emption,you should become subject to the Workers'Compensation APPLIANCE _ 4,00 PLAN CHECK ' provisions of the Labor Cade, you must forthwith.comply with FEE U Such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) - 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000GRM.) 5.00 - SEISMIC FEE I hereby affirm that there is a construction lending agency lot EXHAUST HOOD (WITH DUCT) 2.00 the performance of the work for which this permit Is issued(Sec. MICROFILM 3097,Civ.C.). • HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 Lender's Address ELECTRIC I certify that l have read this application and stale that the above VENTI LATION.FAN'(SING LE) 3.00 information n correct I agree to comply with all city and county 1 PLUMBING information and surto lows relating to building construction, and,my BOILER-COMP I3 H.P.Or 100,000 B.T.U. ) 4.00 hereby authorize representatives of this city.to after ,Pon the above-mentioned property for inspection purposes. BOILER-COMP(ON.,100,000 BTUI SEE FEE SCH. MECHANICAL ' - Dile) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX may in any way'accrue against said City inconsequence of the grant in of this perm,. MECH.CONT. LIC.NO. MECH. �l TOTAL TOTAL ry 00 Signature of Applicant/ ontrach DP[c - OFFICE COPY