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7183APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER BUILDING DDIRS /y $ BUILDING - ELECTRICAL- PLUMBING - MECHANICAL 7183 OW R'S • NAME QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION CONTRACTORS NAME , UTLETS -SWITCHES-RECEP 5.00/1.00 LIGHTING FIXTURES 5.00/1.00 5i�rr /!CI7S uc.No. (CONTRACTOR'S A GDR Ess APPLIANCES -RESIDENTIAL 4.00 PANELS 5.00 S PHONE •BOO DATE OF APPLICATION ARCHITECT OR ENGINEER uc. No. SIGNS 6.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 PITCH. OR ENG, ADDRESS SPECIAL CIRCUIT 5,00 PERMIT VALIDATION EMP. METER OR POLE INS. 15.00 ZIP / J' APPLICANT 9 ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 jJ ' LICENSED CONI RACfORS DECLARATION I hereby affirm that 1 mil licensed tinder provisions of Cllapter 9 (commencing with Section 7000) of Division 3 of the Rosiness and P,o Ic,sions Code nil n license, is in full force u d BIT License lass_�1Z Lia Numbcr3d�o Dales. ��83 Cnmmclors�'«_�_IT ISSUANCE DATE BLDG. ❑ ELECT. ❑ PLG. MECH. ❑ 1 ❑ BUILDING PERMIT OWNER -BUILDER DECLARATION hereby affirm ihut I so uxce.7 from thecontmetor's LIeCIuc Law JOE the,followingreason.(Sec7ires a xusinessandtrct.a Ions Code: Any cilymcounly which rtquircsapermit to construct.a alter, improve, demolish, or repair any'structure, prior to its issuance, also 'INFORMATION MISC.- REFER TO ORD VALUATION' ,4? D $/FT. PERMIT ISSUANCE 6.00 ELEC. CONTR. LIC. NO. ELEC requires the applicant for such permit t0 file a signed statement that Ise is licensed pursuant to the provisions of the Contractors License Law (Chapter9(commencingwith Scction 7000) of Division Solthe Business and Professions Code) or that he is exempt therefrom and TOTAL PERMIT TO P.<)��&?C4rr Je*LL QTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. the basis for the allcgedexemption. Anyviolation of Section703L5 - by any applicant for a permit subjects the applicant to a civil penalty of not mom than five hundred dollars ($500)): ❑I, as owner of the properly, or my employees with wages as their side com pcns:dion, will do the work, and lite structure is not y ALTER -DRAIN & VENT -WATER IEA.) 4.00 BACK FLOW PROTECT. DEVICE 2.00 DCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 4.00 or offered for sale (Sec. 7044, xusiness and Professions Code;ed Code: The Contractor's License Law does not apply to an owner Of FIXTURES - PER TRAP 4.00 - so. PT. FLOOR AREA ' TOTAL ACREAGE property who builds or improves thereon, and who does such work himscll or through his own employees, provided that such intpmve- mentsurenotintendedorofferedforsale. If, however, the building GAS - EA. SYSTEM - I INC.4 OUTLETS 4.00 or improvement is sold within one year of completion, the Owner- builder will have the burden of proving that he did not build or im- proveforpurposeofsale.). ❑ I, as Owner nl' the property, am exclusively contracting with GAS - EA. SYSTEM - OVER 4 (EA.) 1.00 BUILDING USE RES_ El CON PB orber IND 1:1❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 20.00 LAWN SPRINKLERS - 1 INC5 V.B. 5.00 LAWN SPRINKLERS - OVER 5 IEA.) 1.00 ASSESSORS PARCEL NO. licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Con ractor's License Law does not apply to an Owner of property who builds or improves thereon, and who can[ructs tor such projects with a PmtfaClof(sl licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT NO. PARCEL NO. ❑ lam oxcmpt under sec. .N.&P.C. rnr this reason WATER HEATER W/VENT 4.00 Owner Date WATER SYSTEM 4.00 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 4.00 WORK E RS'C'OM PENSA'I'ION DECLARATION I hcrcby affirm that l have a cetllflcaleofconwitt loself-insure. or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. 'copy thereoffSeE 3800, Lab.f-.) r Policy Ni Company �tO47 rr •5'r Ll CCtlilh> ishembyalR L ❑ Ccr[ihcJ(01c op Applicam the El Elpectmn division. 4L�L7 a FIRE$PRINK Y ❑ N ❑ ENERGY T-24 Y ❑ N❑ MISC. - REFER TO ORD. CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C. PLG. CONTR. LIC. NO. PLG. TOTAL COMPENSATION INSURANCE (I his section need not he completed if [he permit is for one Y ❑ N ❑ Y ❑ N❑ hundred dollars IS 100) or less) I certify that in the performance of the work for which [his per- mit is issued. I shall not employ any person in any manner so as to QTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING Sys become subject to the Workeri Compensation Laws of California. Dale Applicant ALTER OR ADD TO MECH. 4.00 NOTICE'f0 APPLICANT: II', after making this Ccr[ificale of lix- APPLIANCE 4.00 PLAN CHECK FEE b empton, you should become subject to the WOrk.' Compenvtion provisions of Ute labor Code, you most forthwith comply with such provisions or this permit shall h deemed invoked. AIR HANDLING UNIT (TO 10,00DC.F.M.) 3.00 AIR HANDLING UNIT(OVER I0=C.F.M.) 5.00 SEISMIC FEE ` 9 CONSIRUCfION LENDING AGENCY I hereby affirm that there is .'Construction lending agency I'or EXHAUST HOOD (WITH DUCT) 2.00 - the performance ol" the work for which this permit is issued (Sec. 3097, Civ.C.L MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 4.00 HEATI NG UN IT [OVER 100,000 B.T.U.)7.50 ELECTRIC Lender's Name Lender's Address I ccrtity the[ I have read this applieation and State that the anovu VENTILATION FAN (SINGLE) 3.00 . imonnation is correct. I agree to comply with all city and county ordinances and stale laws relating to building construction, and PLUMBING BOILER-CONP (3 H.P. or 100,000 B.T.U.) 4.00 BOILER -COMP (Osa.,100,00051-1.1 SEE FEESCH. ,MECHANICAL hereby authorize; representatives of this city to enter upon the above-mentioned property for inspection purposes. MISC. - • REFER TO ORD. (We) agree to ave, indemnify a keep harmlew the City of Cupertino a "rtst liabilities, judg s, Costs and expenses which may in it way accrue ga'n d City in consequence of the CONST. TAX PERMIT ISSUANCE 3.00 granting permit. ' �� MECH. CONT. LIC. N0. MECH. TOTAL TOTAL Ij 7 -2 ' ' nature od'Applicaro/Clottractor Date f„� INSPECTOR COPY