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8306APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTI FICATION APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING -MECHANICAL PERMIT NUMBER (� 8306 BUILDING ADDRESS U35lz ��� 577 OWNER'S rvnME C ' n /? //ONE OTV. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION 3 ds DATE OF APPLICATION CONTRACTORS NAME � LIC. NO, 6%5t7- OUTLETS-SWITCHES-RECEP 10.00/1.00 ILIGHTING FIXTURES 10.00/1.00 NTRA ADDRESCTOR's A D eR, PHONE Z APPLIANCES - RESIDENTIAL 4.00 PANELS 10.00 ARCHITECT OR O ENGINEER LIC. No. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. N0. SIGNS TRANS. 3.00 ARCH. OR ENG. AooREss SPECIAL CIRCUIT 5.00 PERMIT VALIDATION EMP. METER OR POLE INS. 20.00 � ZIP C ' //s _ ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Pu, IcS,mna Codi nd my Ilmnsc is in full Luca a and effect. License Class- _ I.he. Number � (_/ S� ISSUANCE DATE BLDG. n ELECT. ❑ PLG. ❑ MECH. ❑ - Date,=Contractor ? LZf1 owNER-BUILDER DELL n'n 1 hereby affirm that I am exempt from theC nlruetor's License Law for the following reason. (See 7031.5, Businessand Professions Cade: Any city orcounty which requires a permit to construct. after, `BUILDING PERMIT INFORMATION MISC.- REFER TO ORD PERMIT ISSUANCE 1000 . VALUATION S/FT. ELEC. CONTR. LIC. NO. ELEC. TOTAL Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for Such permit to file a signed statement that h, is licensed pursuant to the provisions of ilia Contractor's License Law (Chapter 9 (commencing with Section 7000) ofDivision 3 of the Business and Professions Code) or that he is exempt therefrom and K/ PERMIT TO QTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of$ection 7031.5 :by any applicant for a permit subjects the applicant to a civil penalty of nut more than five hundred dollars (S5o01.1: ALTER -DRAIN -WATER (EA.) 5.00 ❑ , I, as owner of the property, or my employees with wages ax BACK FLOW PROTECT. DEVICE 4.00 their sole compensation, will do the work, and the structure is not OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00 'mended'or offered for sale (Sec 7144, Business and professior, Code: The Contractor's License Law does not apply to an owner of FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE properly who builds or improves thereon, and who does such work himself or through his own employees, provided that such inlprove- maisare not intended or offered for at,. l L however, the building GAS -EA. SYSTEM- 1 INC. 4 OUTLETS 6.00 or imprmement is Sold within nue year of completion, the owner- . .. GAS - EASYSTEM -OVER 4 (EA.) 200 BUILDING USE builder will have the burden of p roving that he did not build or am- INDUSTRIAL WASTE INTER. 30.00 Prove for purpose of sale.). RES IND CON PB Other ❑ I, as owner of the property, am exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors to construct the project (Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Code: The ConUacmr's License Low dyes not apply LAWN SPRINKLERS - OVER 5 IEA.) 1.00 to an owner of property who builds or improves thereon, and who contracts for such projects with a contractors) licensed pursuant to SEWER -SAN EA. 200ft/10.00 TRACT NO. PARCEL NO. the Contractors License Law. ❑ I um exempt Ruder Sar.-, B,&P.C. In, this reason WATER HEATER W/VENT 6.00 OwnerDal, WATER SYSTEM 5.00 ACC.DATE ACC. FILE No. WORK ERS'COMPENSATION DECLARATION 1 WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent to scl Ginsve, Or a certificate of Workers' Compensation Insurance, or a cerlilsd ZONING ENG. SITE N0, copy thereof (Sec. 3800, Lab.C.). - Rule, No. Company FIRE SPRINK ENERGY T 24 ❑ Certified copy is hereby furnished Certified copy is filed with the city' inspection division. Apti, MISC.- REFER TO ORD. v❑ N❑ v❑ N❑ CE TIPICI' 1. 1' EXEMPTION FROM WORKIikS' PERMIT ISSUANCE 10,00 FLOOD ZOrvE A. L.U.C. COMPENSATION INSURANCE PLG.CONTR. LIC. NO. PLG. I This action need not be Completed if the permit is for one TOTAL Y ❑ N ❑ Y ❑ N❑ hundred dollars (5100) or lcssf I certify that in the pmfornan,a of the work for which this par- CITYMECHANICAL PERMIT FEE FEE SUMMARY nm i, Insued, 1 hall not employ any person in any Rnanner .sae as to become subject to lire Workers' Compensation Laws of California. ALTER OR ADD TO MECH. 5.00 Date Applicant BUILDING NOTICE TO APPLICANT: If, after making this Certificate of Ex- APPLIANCE 5.00 PLAN CHECK emption, you Should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith conRply with FEE ' such provisions or this permit shall be demned revoked. AIR HANDLING UNIT (TO 10SWC.F.M.) 4.00 AIR HANDLING UNIT(OVER 10=C.F.M.)6.00 SEISMIC FEE CONSTRUCTION L17NDING AGENCY 1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 lire performance Of the work for which this permit is issued (Sec. MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 30(17, Civ.C.). Lender's Nam, Lender's Address HEATING UNIT (OV ER 100,000 B.T.U.)9.50 ELECTRIC 1 Certify' that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 information is correct. 1 agree to comply with all city and county PLUMBING ordinances and sial, laws calming to building esmwoction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00 BOILER ' Hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL (We) agree to save, indemnify and keep harmless the City of MISC.. REFER TO ORD. -' Cupertino against liabilities, judgments, costs and expenses which CONST. may in any way accrue against said 'ty in Lronsequcnce of the PERMIT ISSUANCE 10.00 -`TAX granting of this permit. r MECH.CONT. LIC. NO. MECH. TOTAL TOTAL [signature ofA pl' nt/Co actor Da