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8845 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LOI NG PROJECT I DENTI FICATI ON PERMIT NUMBER BGILOING APPLICATION & PERMIT AOO-PESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAF©1 A r N R PLAN CHECK VALIDATION NAME OTY. ELECTRIC PERMIT FEE PXON -A NAME nciona UTLETS-SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 CONTRACTORSADDREssPPLIANCES-RESIDENTIAL 4.00 PHON PANELS 10.00 DATE OF APPLICATION OARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. ENGINEER LIC.NO. SIGNS TRANS. 3.00 nooa'Eag ENc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP EMP. METER OR POLE INS. 20.00 APPLICANT'S -Y.,(fR�"" AooPEss MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 0 O LICENSED CONTRACTORS DECLARATION TEMP.POLE • 30.00 / 0 a u 1 hereby affirm that I am licensed under provisions of Chapter 9 2 w y ¢$ (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE BLDG. ELECT. PLG. MECH. H y z Professions Co( a.d .license is in full fo(p f(pcya ❑ ❑ ❑ " 2 o m _/ License s V Lic.Nombe g is Z r Dmc 'Contractor ¢ ¢ w a OWNER-BUILDER DECLARATION BUILDING PERMIT. w- 0A0 MISC.- REFER TO ORD INFORMATION ; LL y 1 hereby affirm Ron I am exempt from the Contractor's License u.O j Law for the following rceSOn.($e0.7031.$,Business and Professions VALUATION $/FT., - PERMIT ISSUANCE 10.00 wi Code:Any city or county which requiresaperinit ioconstrreL alter, aa ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEG. S. - u requires the applicant for such permit to file a signed statement that wTOTAL $ he is licensed pursuant to the provisions of the Contractor's License IT TO H z a Law(Chapter 9(commencing with Section 7000)of Division 3 of the ePER i O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE a r $ the basis for the alleged exemption.Any violation of Section 7031.5 _ STORIES TYPE CONSTR. by not more firm permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars(8500).): ❑ I•as owner of the property or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's License Luse does not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 BG.FT,FLOOR AREA TOTALACREAGE • himself re through his own ffe,ed employees,provided that such improve or rls improvemenotnt is sold within one year ((,however,the theo owner- builder GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 or improvement it sold within mac year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 builder will have the burden of proving that he did not build or im- BUILDING USE prove for purpose of sale.). I NDUSTRIAL WASTE INTER. 30.00 _RES IND CON PB Omer ❑ d as owner of the property,he exclusively contracting with O licensed contractors to construct the project(Sec. 7044•Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. toProfessions Cole:The Contractor's License Law does not apply - to tr owner of property who builds improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a contrtracmrtel licensed Vursuanl to the Contractor's License Law. SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO. PARCEL NO. ❑ I am exempt under Sec. ,B.&P.C.liu this reasonWATER HEATER W/VENT 6.00 Owner - Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate ofconsent to sel Ginsure, or a certificate of Wotkers'Compensation Insurance,or a Certified ZONING ENG.SITE NO. copy(h pp((j�$ �3gpQ,Lab.C. . Policy N�Ld p(O[(�Spany t,.,r�c(�7 � AA x� C) ❑ Certified copy is hereby funushed. FIRE SPRINK ENERGY T'24 Z Z Certi d o rs f+l y�I the city inspection division. H O I plicunt N`42 " MISC.- REFER TO ORD, y E] No Y C] NE] cc CERTIFICA'rFOFEXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. LU COMPENSATION INSURANCE PLG.CONTR. uC.NO. PLG. 1 O (This section need not be completed if the permit is for one TOTAL Y N� Y❑ NC] 0 Z hundred dollars(S 100)or less.) U O I certify that in the performance of the work for which this peri MECHANICAL PERMIT FEE < FEE SUMMARY 8 LL F- mit is issued,I slmll not employ any person in any manner so as to O W become subject to the Workers'Compensation laws of California. BUILDING OL Date.Applicant ALTER OR ADD TO MECH. 5.00 } N NOTICE TO APPLICANT: If,after making this Certificate of Ex- F Z emption,you should become Subject to the Workers'Compensation APPLIANCE P' _ - 5. PLAN CHECK provisions io the labor Code, you must forthwith comply with FEE CJ such Provisions or this permit shall be deemed invoked. AIR HANDLING UNIT(TO 10,000 M.Is 4.00 - CONS'I'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10UCT)GEM.) SEISMICFEE 1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH D 0 the performance of the work for which this permit is issued(Sec MICROFILM 3097,Civ.CJ. HEATING UNIT(TO 100,000 B. .U.) 8.00 Lender's Name Lender's Address HEATING UNIT(OVER 100,000 B.T.U.0.50 -L& ELECTRIC I certify that I have read this application and state than the above VENTILATION FAN (SINGLE) 4.00 . information n correct. 1 agree to comply with all city and county BOILER H.P.Or 100,000 B.T.U.) 6.00 PLUMBING ordinances and state laws relating to building construction, and S hereby authorize representatives ins of this city to enter upon th` BOILER-COMP ver 00,000 TUI SEE FEE SCH. MECHANICAL f abovumnnlioned property for inspection purposes. (We) agree to save,indemnify and keep harmless the City o1' C.- FFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which CONST.TAX ma in any way, accrue salon said City in consequence of the (SSU N E 10.00 It ing Oft is perm it, MECH.CONT. LIC.NO. MECH. It' TOTAL TOTAL Ignature of Applicant/Contract Dane SO OFFICE COPY