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9315 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER BDILDING APPLICATION & PERMIT (� ADDRESS LDING —ELECTRICAL—PLUMBING—MECHANICAL `qtoIo nJ • �la� e]133 15 OWNER'5 PLAN CHECK VALIDATION X NAME QTY. ELECTRIC PERMIT FEE 1 1DEN N e ZAJTc C PHDNE -7 j croR NAME UTLETS-SWITCHES-RECEP 10.00/1.00 NAME IN— _ LIC.NC, LIGHTING FIXTURES 10.00/1.00 CONTRACTORS AIIR�lPPLIANCES-RESIDENTIAL 4.00 AODREss 11 % 1Y'J PHONE — PANELS 10.00 DATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. o OR ENGINEER Llc.NO. SIGNS TRANS. 3.00 ARCHE OR ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION zlv EMP.METER OR POLE INS. 20.00 ADRMOTORS SEE FEE SCH. ADDRESS SERVICE CHANGE 20.00 i 0 '00 LICENSI 1)CONTRACTORS DECLARATION TEMP.POLE 30.00 / '�f ` ¢u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE m< N (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. r m z Professions Code,and my license is in full force and effect o o License CLic.Number zS _ ❑ Elx A© _Contractor ¢ Y s BUILDING PERMIT ¢ ¢ w ¢ OWNER-BUILDER DECLARATION cu . INFORMATION o A. " MISC.— REFER TO ORD E: ¢m I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT. r a-o J Law For the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE ` 10.00 Code:Any city or county which requires a permitro construct,alter, Qac ¢ 2 improve,demolish,or repair;my structure,prior to its SSLaneC,also ELEC.CONTR. LIC,NO. ELEC. D ¢ requires the applicant for such permit t0 file a signed statement that TOTAL PERMIT TO wm he is licensed pursuant to the provisions of the Contractor's License i Law(Chapter 9(commencing`vith Section 7000)of Division 3 of the �L C/ / 5 i a I)usincss and Professions Codcl or that he is exempt therefrom and CITV. PLUMBING PERMIT FEE �1fs N ¢ r o the basis fur the alleged exemption.Any violation of Section703 LS STORIES TYPE CONSTR. ca T by any applicant for a permit subjeus the applicant pact civil penaltyALTER-DRAIN& VENT-WATER IEA.15A0 of not more than five hundred dollars(55000.): ❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 their sole contpensalion,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 Law does not apply to an owner of property who builds or Improves thereon,and who does such work FIXTURES-PER TRAP ..S-OQ li` SO.FT,FLOOR AREA TOTALACREAGE . pent,(or not hrough own employees, le.11,edthmsuch improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6 mems arc not intended or offered ees,pr If,ed that S The building or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE builder will have the burden of proving that he did nut build or To RES TND CON PB Omar Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ El El ❑ El 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 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(s)licensed pursuant to the Contractor's Lice use Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ I am exempt under Sic.—,B.&P.C.for this WATER HEATER W/VENT 6.00 1 reason Owner Dale WATER SYSTEM 5.00 ACC.GATE ACC.FILE NO. WORK17RSCOMPENJA'1'I0N UECLARA'f ION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified copy tltereof(See.3800,Lab.CJ. PoBry No. Company ��2 OAQ Q ❑ Cerlilled copy ix hereby lurmshed. FIRESPRINK ENERGYT24 _Z Z hr Certified copy is fled with the city inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑ Ap licent _ V N V N ~ D CliIfTIPICPERMIT ISSUANCE 10-0 jr > COMPENSATION INSURA CE LRS Q.PLG.CONTR. LIC.NO. PLG Q C FLOOD ZONE A.L.U.C. 1 V N V N Z hundred action need not be completed if the permit is for one TOTAL a (/� ❑ ❑ ❑ ❑ hundred dollars l5100)or less.) 0 O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY LL H mit is issued,I shall not employ anylperson in any manner so as to U become subject to The Workers Compeamaten Laws of California. UJ C. aze DApplicant ALTER OR ADD TO MECH. 5.00 BUILDING } N NOTICE TO APPLICANT: If,after making this Certificate of Ex Z e...ption,you should become subject to the Workers Compensation APPLIANCE 5,00 PLAN CHECK provisions of The Labor Code,.you .,of Ibrth,,uh comply with FEE CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT TO 10=C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY N AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE I hereby affirm that There is a construction lending agency far EXHAUST HOOD (WITH DUCT) 5.00 the 3097 .).eCi,.0w of The work I'or which this permit is issMICROFILM ued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 information is correct. I agree to comply with all city and county PLUMBING Qp ordinances and spite laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which CONST.TAX may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 LIC.NO. MECH. TOTAL TOTAL granting of this permit. MECH.CONT. IT \ Sil lh Fn App ant/ -t clor )tc 107 INSPECTOR COPY