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8366 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENT[FI CATION PERMIT NUMBER BoILDING55 b b APPLICATION & PERMIT ^A -.}. NOORE S- ala nC q V e- BUILDING - ELECTRICAL-PLUMBING-MECHANICAL OWNER'S PLAN CHECK VALIDATION NAME (�rye 6 QTY. ELECTRIC PERMIT FEE C"T 1 YG L //_V 1�%6 PHONE NAMERAcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00 f' LIC.No, LIGHTING FIXTURES 10.00/1.00 CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 Ae - PHONE PANELS 10,00 DATE OF APPLICATION ARCHITECT 0. PANELS (OV R 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. ENGINEER LIC.NO. SIGNS TRAN 3.00 ARCH.OR ADDRESS ENG SPECIAL CIRCUIT 5.00 J-- PERMIT VALIDATION ZIP EMP.METER OR POLE INS. 20.00 aoOREss APPLICANT'$ MOTORS SEE FEE SCH. S77 SERVICE CHANGE 20.00 l 02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 rt Z W, 1 hereby afl'inn thin I an licensed under provisions of Chapter 9 ISSUANCE DATE N ¢ (cont mm�cing with Seclion 7000)of Division 3 of Ilse Business and BLDG- ELECT. PLG. MECH. H y z Professions Code,and my license is in full force and effect ❑ ❑ ❑ ❑ z 0 m W License Class Lie.Number 9 Date Contractor '' Y. a a s BUILDING PERMIT ¢ ¢ w a OWNER-BUILDER DECLARATION a 0 a U INFORMATION X I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD Foo¢ Law for the following reason. 7031.5.Business and Professions PERMIT ISSUANCE �90 VALUATION $/FT. iA Code:Any City or county which requires permit to construct,alter, CE a, a Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. iii a O ¢ requires the applicant for such permit to file a signed statement that TOTAL O PERMIT TO A w m m he is licensed pursuant to the provisions of the Contractor's License HZQ Law(Chapter 9(coonnencing with Section 7000)olDivision 3 of the ELEG �' P�� 4 o Business and Professions Code)or that he is exempt therefrom and - ¢ I-o the basis for the alleged exemption.Any violation of QTY. PLUMBING PERMIT FEE /Section]031.5 STORIES TYPE CONSTR. d ; '2 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars(5500).): ❑ 1,as owner of the property,or Iffy employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS their sole c mpensafion,will do the work,and tire tn e smture is not intended or offend fur sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00 ' ' - Code:,Me 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 5.00 so.PT.FLOOR AREA TOTAL ACREAGE himself re through his own employees,provided that such improve or improvemenotnt tendril on within onefor yearl o If,howeveq the the o nee- GAS-EA.SVSTEM-l1NC.40UTLETS 6.00 1 or improvement is e h within one year of completion, the owner- GAS-EA. VSTEM-OVER 4 (EA.) 2.00 builder will have the harden of proving that he did not M1uild or int. BUILDING USE prove for purpose of sale.). INDUSTRIAL WASTE I INTER. 30.00 RES IND CON PB Omer ❑ 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.8. 6.00 ASSESSORS PARCEL NO. and Professions Code:T'he 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 enntrucmAs)licensed pursuant to the Contractor's License Law. SEWER-SAN ITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ Iwo exempt under Sec ,R.&P.C.for this WATER HEATER W/VENT 6.00 OwnerO Owner reason Date tf` pp WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. N'O 'IiRS'COM1IPENSA'I'10 N DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm than I have it Certificate of resent to sell-insure, ZONING ENC.SITE NO. or a cerlificate of Workers'Compensation Insurance,or a certified copy Rmrcof(Sec.3800,Lar.C.L t Policy No. Company 0pJ Certified copy is hereby furnished. FIRE SPRINK ENERGY T24 Z Z C? Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. 0 Applicant V❑ INC] V ❑ N❑ Fy PERMIT ISSUANCE FLOOD ZONE A.L.U.C. LU CER'I'1 FICADIPE EXEMPTION INS PROM WORKERS' W � COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. QL 0 (This section need not be completed if the permit is for one TOTAL O Y❑ IN Y ❑ N❑ 0 Z hundred dollars IS 100)or lC.,) U O 1 cratil'y that in tire PCrfurmunre of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F- mit is issued,1 shall not employ any person in any nlamerm as to 0 w become subject to the W'orkcri Compensation Laws of California. a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } m NOTICE TO APPLICANT: If,after making this Certificate of Ex- F- Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith cont Ply with FEE U such provisions or Ili,permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 CONS'rR UCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 the performance of the work for which this permit is issued(Sec MICROFILM 3097,Civ.CJ, HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender',Name H EATING UNIT(OV ER 100,000 B.T.U.)9.50 Lender's nddress ELECTRIC cs�Q I cert ily that l have read this applicm ion and state ilial the above VENTILATION FAN (SINGLE) 4.00 information n correct I agree to comply with all city and county g01 LER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING information and state laws relating to building construction, and hereby authorize representatives for ins of this City to enter ,on the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL herebyalbove- ned property forinsp of this purposes. (We) agree to save, indemnify mol keep harmlCss 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 acerae against Said City in consequence of the granting of this permit. MECH.CONT. LIG N0. MECH. r TOTAL TOTAL Sig A I cant/Cont actor I al 3 0 `1 INSPECTOR COPY