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C 3392 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONLY BUPERMIT NUMBER - t - ILDING.PROJECTlDENTIFICATION, APPLICATION & PERMIT ' AWL-"� C � 3392 SO ss .0 BUILDING - ELECTRICAL-PLUMBING -MECHANICAL 1 Got S - - - - - '-- - --- --_--- - _ - PLAN CHECK VALIDATION "AMe l)PPHONE - QTY. ELECTRIC PERMIT FEE GN E /$ NAAMERAcroRs UTLETS'-SWITCHES-RECEP 5.00/1.00 w/IL/I ZU4' LIGHTING FIXTURES 5.00/1.00 CCNTRACTORS - Al - - 'APPLIANCES-RESIDENTIAL 4.00 ADDRESS - j' P•D.?CfI abC PRONE Y97-10 30. PANELS _ 5.00 DATE OF APPLICATION ARCHITECT - SIGNS 6.00 PLAN CHECK FEE P.C.NO. OR ,ENGINEER' L1. IC,NO. SIGNS TRANS.- 3.00 ADDRESS eNa. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION - ZIP rrEMP.METER OR POLE INS. 15.00 - - APPLICANTS MOTORS SEE FEE SCH. ' ' 7 ' ADDRESS - .y,. SERVICE CHANGE 10.00 'I}�'/ p / oo LICENSED CONTRACTORS DECLARAT ION '// � O'� a v U I hereby affirm that I am licensed under provisions of Cliaptci 9 ISS///DANCE GATE w (commencing with Section 70001 of Division 3 Of the Buainess and ¢ n a D ELECT., PLG. MECH- r w i Professions C�1- ue is in lull I'orc'I�a 'Te� _- ❑ - ❑ ❑ r o i m o License ^ 1-ic.Number' N r Date Cont mcmr_Y7/ I BUILDING PERMIT re rc w - OWNER-BUILDER DECLARATION } " o a. MISC.- REFER TO ORD i • INFORMATION L 0 H 1 hereby affirm that I am exempt.from the Contractor's License a LL o ¢ Law for the following reason.(Sec.7031.5,Basiliec and Pndessions PERMIT ISSUANCE 6.00 VALUATION - S/FT- � us� � Code:Any city or County whichrequimsapermitloconstn¢t,alteL ,/ Ori - ¢ ¢.O improve,denmlish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.N0. ELEC. at O u requires the applicant for such penmit'to file a signed statement that ', TOTAL (I,IiER MIT T u w m m Ie is licensed pursuant to the provisions of the Contractor's License aid E. z Law(Chapter?(commencing with Section 7000)of Divisi�n3nf the 5 1 a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE (` ' .Ic ­ 0 the basis for the alleged exemption.Any violation of Section703L5 ;_' STORIES It s./� TVP CO OR. g: by any applicant for a permit subjects the applicant loo civil penalty - gLTER-DRAIN & VENT-WATE1. R (EA.) 4.00 ll of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE . �e their sole compensation,will do the work,and the structure is not 2.00 'IJ V CCa ,�OP In REB.UNITS 1 intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who dins such work FIXTURES-PER TRAP 4.00 So.FT.FLOOR AREA TOTAL ACREAGE - himself or through his own employees.Provided that such improve^ . mems are not intended or Offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.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 he did not build or im- provefor Purpose ofsale.-1. INDUSTRIAL WASTE INTER. RES IN Co Pa Ome, ❑ 1,as owner of the property,am exClusivCly contracting with 20'00 ❑ ❑ licensed contractors to construct ate praHer(Sec.7044, Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSLSSU/5WHCEL NO. and Professions Code:The Contractor's License Law does not apply to an owner of property win builds or improves thereon.and who LAWN SPRINKLERS 5(EA.) 1.00 _ contracts forsuch projects with o contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/B.00 . the Contractors License Law. TRACT NO. PARCEL NO. ❑ I um exempt under Sec. WATER HEATER W/VENT 4.00 reusov Dam Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILEND. WORKERS'COMIIiNSA'I'ION DECLARA'[ION WATER TREATING EQUIP. 4.00 I hereby affirm that I has OW'. titan cute of consmn to self-insure, or ce'lifieate of t�/a/Va ton Insurance,or n cert il'cd ZONING ENG.SITE N0. . copy tic orp 6 ILn C� 1 . Policy N Company_1r�'�''',,L . O O Certified copy is hereby farnis,e' ,I FIRE BPRINK ENERGY T44' Z Z !� Certified copy I, Filed with the uty inspeetion div�on, ' O Ann can MISC.-. REFER TO ORD. Y ❑' N❑ Y Q. N[] 1-_y PERMIT ISSUANCE 6.00 LU - l'IiR'IIPICA'TE(IIs SATION ION FRONI WORKERS' FLooO2orvE A.L,u U.C. W > COMPENSATION INS URANCI? I PLG.CONTE. - LIC.NO. PLG. d O (This se,hou need nut he completed if the permil Is fm one' '+ - TOTAL Y❑ NE] Y❑ No D Z huodreddollms(SIOO)or C..) - U O'' I certify that in the performance of thework forwhich this pew QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL E- mit is issued,I Shall not employ any person in any manne so as to .'O w become subject to the Workers''Compensation Laws of California. St. Dmu Applicant ALTER OR ADD TO MECH. 4.00 - BUILDING S� , �-'Ca NOTICE TO APPLICANT: If,after making this Certificate of fix- •F Z mnption.you should b Come son,,el to the Workers'Compensation APPLIANCE 4.00 PL N CHECK provisions of the Labor Code, you must forthwith comply with ' U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 101 3.00 . CONSTRUC'TION LENDING AGENCY AIR HANDLING UNIT(OVER 110MQEM.) 5.00 SEISMIC FEE - I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 the ranee of the work for which this permit is issued(Sec. MICROFILM Lnde7.Lender's CO.Na 1. - HEATING UNIT(TO100,000 B.T.U.) 4.00 Leender's Name HEATING UNIT(OVER 100,000 B.T.U.17.50 ' 1-undds Address - ELECTRIC � I certify that I have read this application and stale teal the above VENTILATION FAN (SINGLE) 3.00 - information is correct. I agree to comply with all city anti county PLUMBING ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 1 hereby authorize representatives of this city es enter upon the BOILEWCOMP IOver toL000 BTU)SEE FEE SCH. ' MECHANICAL above hereby authorize entioned property for inspection purposes to, - (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,Judgn •its, costs and axpeoaes which PERMIT ISSUANCE 3.00 CONST.TAX may*)( iisperinit. ccrue agai t id City in conser cone f the • g tin, Ecu.CONT. LIG NO. MECHa,c �� OTALTOTAL Ig aan Contr ctor' Date OFFICE COPY - --_1