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C 09700 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION • PERMIT NUMBER t . ,LOG kitinIa APPLICATION & PERMIT ADG5 ELECTRICAL—PLUMBING—MECHANICAL 09700,A OOcct — Ilf 1 OWNER'S NAME — PLAN CHECK VALIDATION (�,� DTV. ELECTRIC PERMIT FEE lel,. OY fe PHONE NOMERAcr&broRslal UTLETS-SWITCHES-RECEP 10.00/1.00 (} Cor, uc.No, LIGHTING FIXTURES 10.00/1.00 CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 ' AG�OrRE55 1/� 1' I` ;s Q vHONE� IQ^l'I N PANELS 10'.00 In DATE OF APPLICATION OR RCHITEcr PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO. ENGINEER Sea1S d- uc.No -IS1 SIGNS TRANS. 3.00 ARCH.OR ENG. ALIOATION AOOREEs SPECIALCIRCUIT 5.00 _ C P A V@ k CL AL1 I EMP.METER OR POLE INS. 20. �� tI ��®� ADORE Nrs MOTORS SEE FEE SCH. U APPLICA 73 So-SCLra 1X1.�W SERVICECHANGE' 20.00 1lgrtino Woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ��CaD Fi W 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE (commencing with Section 7000)of Division 3 of the Business and ES PLG MECH. r m i Professions Cod nJ my license is in full fo ec z o w License�1{'i�s��T Lic.Number gDntc—ILL-I-$,_.Contraclor k?r('yY F N F Q y f J ¢ ¢ w OWNER-BUILDER DECLARATION - ,BUIL RMA ION MISC.— - REFER TO ORD INFORMATION' F ;u 1 hereby affirm Ilett I am exempt from the Contractor's License VALUATION LL o Law for the follbwL reason.ch re uires a,permit to construct,nd Professions 10.00 : /T r - g PERMIT ISSUANCE IC/�Yf(/L]f Code:Any city or roe my which requirese permit to uanahaq ¢ ¢¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. wD LL requires the applicant]or such permit to file a signed statement that TOTAL $ he is licensed pursuant to the provisions of the Contractor's License PERMIT TO rzi Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe E E o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE - ¢ s-$ the basis for the alleged exemption Any violation of Section malty STOR TYPE 00 TH. dLoa; - by any applicant for permit subjects thecivil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars($500t): ❑ I,as owner of the property,or my employees employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.[NITS their sole compensation,will(S the work,and the re is not intended or offered for sale (Sec. 7044, Business anti Professions ROOF,AREA,COND. 5.00 Code:The Contractor's License Law does not apply to an owner work property who builds ar improves thereto,and who docs such work FIXTURES-PER TRAP S,OO SO. .FLOOR REq TOTALACREAGE eD himself or through his own employees,provided That such improve- r� ments are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-1 INC.4 OUTLETS 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 an. GAS-EA.SYSTEM-OVER 4(EA.) 2,00 BUILDING USE prove for purpose of sale.). INDUSTRIAL WASTE m INTER. 30.00 E I❑ ❑N PS❑ Other❑ ❑ 1,as owner of the property,aexclusively contracting with licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO. 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-OVER 5 (EA.) 1.00 contracts for such projects with a Contractor(.,)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00RqC NO. PARCEL NO. ❑ lam exempt under See ,B.&P.C.for this I WATER HEATERW/VENT 6.00 Owner Owner DateWATER SYSTEM 5,00 qt DATE ACC.FILE NO. WORKERS'COMPENSAT'ION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate of amsem to self-insure, or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO. copt La L.0 Policy No.off5ec.38Co pany,).�)SF4 C7 O ❑ Certified ropy is hereby furnished. Z Z NeCertif• op is led w ,• c y' Ilion division. FIRE SPRINK ENERGY T2 F O Applicant MISC.- REFER TO ORD, Y❑ N E] v ❑ N� CC CERTIFICATE OF EXEMPTION FRU WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE a.L.U.C. UJ COMPENSA'T'ION INSURANCE PLG.CONTR. LIC.No. PLG. 1 O (This section need not be completed if the permit is for one TOTAL V[J NEI V [ NE] Z hundred dollars IS 100)or less.) U O 1 certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY' LL I- mit is issued,1 shall not employ any person in any manner so as to Q W become subject to the Workers'Compensation Laws of California. y Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } N NOTICE TO APPLICANT: If,after making this Certificate of 1?x- ? emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK / provisions of the Labor Code, you must forthwith comply with FEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 �) CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 6.00 SEISMIC FEE rD� I hereby affirm that there is a construction lending agency for I EXHAUST HOOD(WITH DUCT) 5.00 the Performmm 1'the warKF�1.�p_r which this permit is issued(Sec. MICROFILM / 3097,Civ.C.), iQ a +--iitn -- HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Nam Lender's nAdre1104 HEATING UNIT(OVER 100,000B.T.U.)9.50 ' ELECTRIC I certify that 1 have read this application and slate that the above VENTILATION FAN (SINGLE) 4,00 40 information n correct. 1 agree to comply with all city and county PLUMBING ordinances and stale laws relating to comply with l city and c, and BOILER-COMP(3 H.P.or 100,0008.T.U.) 6.00 herebhereby authorize representatives ec this city to enter upon the abovees BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL 31 y authorize ned property forinsp of tion putty to (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX may in any way accrue against said City in consequence of the rant' of this per - MECH.CONT. LIC.NO. MECH. c q 10 K TOTAL TOTAL t Gf igna collicant Contractor Date OFFICE COPY