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9076I IX O Z Z O LU > ao Z) z UO U_ U OW >_a U) F- Z .+ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION &PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 9076 BUILDING AD D ESS 7�%a N�'� , O N R'S NAM ,. J/ /{ �. �/ 4--, ., ELECTRIC PERMIT FEE PLAN CHECK VALIDATION DATE OF APPLICATION CONTRACTOR'S NAME LIC. NO. OUTLETS - SWITCHES - RECEP 10.00/1.00 ja - LIGHTING FIXTURES 10.00/1.00 lo CONTRACTOR'S ADDRESS PHONE APPLIANCES - RESIDENTIAL 4.00 PANELS 10.00 ARCHITECT OR ENGINEER LIC NO. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ARCH . OR ADDRESS ENG. zIP SPECIAL CIRCUIT 5,00 PERMIT VALIDATION �/ X' ISS ANCE DATE EMP. METER OR POLE INS. 20.00 APPLICANT'S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class Lic. Number Date Contractor OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, 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 Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- ments are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or im- prove for purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. ❑ I am exempt ider S B.&P.C. fo this reason TEMP. POLE / 30.00 BLDG. ❑ ELECT. PLG. El MECH. , "� t BUILDING PERMIT INFORMATION MISC. - ` PERMIT ISSUANCE 10.00 VALUATION $/FT. ELEC. CONTR. LIC. NO. ELEC. 7 TOTAL e10 -- PERMIT TO _ QTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. ALTER -DRAIN &VENT -WATER (EA.) 5.00 BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00 FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTALACREAGE GAS - EA. SYSTEM - 1 I NC.4 OUTLETS 6.00 GAS EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE RES IND CON PB Other ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. LAWN SPRINKLERS - OVER 5 (EA.) 1.00 SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. WATER HEATER W/VENT 6.00 Owner Date WORKERS' OMPENSATION DECLARATION l hereby affirm that 1 have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab.C.). Policy No. Company ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the city inspection division. Applicant n WATER SYSTEM 5.00 L ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 ZONING ENG. SITE NO. FIRE SPRINK Y❑ NEI ENERGY T-24 Y E] NEI MISC. REFER TO ORD. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) 1 certify that in the performance of the work for which this per- mit is issued, 1 shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Applicant PERMIT ISSUANCE 10.00 FLOOD ZONE Y ❑ NE] A. L. U. C. Y [:] N PLG. CONTR. LIC. NO. PLG. TOTAL OTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING ALTER OR ADD TO MECH. 5.00 NOTICE TO APPLICANT: If, after making this Certificate of Ex- 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. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ.C.). APPLIANCE 5.00 PLAN CHECK FEE AIR HANDLING UNIT (TO 10=C.F.M.) 4.00 AIR HANDLING UNIT (OVER 10)[00C.F.M.) 6.00 SEISMIC FEE EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address 1 certify that I have read this application and state that the above information is correct. 1 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. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments costs and expenses which may in any way accrue City in consequence of the granti rs pe HEATING UNIT (OVER 100,000 B.T.U.)9.50` ELECTRIC '36 VENTILATION FAN (SINGLE) 4.00 PLUMBING BOILER- COMP (3 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL MISC. - REFER TO ORD. CONST. TAX PERMIT ISSUANCE 10.00 MECH. CONT. LIC. NO. MECH. TOTAL TOTAL Signature of A rcant/Contractor Date OFFICE COPY