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8754APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER $754 BUILDING UREss &hh AD O 5 d NAME x ��J QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION or NAME AACTORs OUTLETS -SWITCHES -RECEP 10.00/1.00 uc. No. LIGHTING FIXTURES 10.00/1.00 Aton nooREss APPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 PRONE DATE OF APPLICATION IEA�WW r on PANELS (OVER 200 AMP) 20.00 (PLAN CHECK FEE P.C. NO. ENGINEER leboouc. No. SIGNS TRANS. 3.00 ADDRESS FG7GR¢ - SPECIAL CIRCUIT 5.00 PER 'I TION zIP 0449 JUL q 19 5 EMP. METER OR POLE INS. 261,00 APPn vPu Ess a rs on MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 City of Cup ertino LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 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 nd my license is i I full force n f License Class - Lic. Numbertor �� N 7 ISSUANCE DATE BLDG. ELECT. PLG. MECH. El 11mc-/,171do ComDECL ���/-�U WthaR-BUILDER DEr.. nT1on I 1 hereby affirm that 1 am exempt from the Cnnlracnr's License Luw For the following reason. (Sea 7031.5, Businessand l'rol'e,dwre' Code Any city .,county which requires a permit io construct, alter, BUILDING PERMIT INFORMATION MISC.- REFER TO ORD PERMIT ISSUANCE 10.00 VALUATION $/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 he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing will, Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and / PERMIT TO OTY. PLUMBING PERMIT FEE the basis for the alleged exemption. Any violation of Section 703 1. 5 by i... y applicant for a permit subjects the appllcan l tnaclvll penalty UI ow InOR than five hundred dollars ($501)7.): ' O 1, .,owner of the property, or ...y employees with wages as their sole compensation, will do the work, and the structure is not STORIES TYPE CONSTR. ALTER -DRAIN -WATER (EA.) 5.00 BACK F LOW PROTECT. DEV ICE 4.00 OCC. GROUP RES, UNITS DRAINS -FLOOR, ROOF, AR EA, COND. 5.00 intended or offered for sale (Sea 7044, Business and Professions Code: Time Contractor's License Law does not apply to an owner of FIXTURES - PER TRAP 5.00 GAS-EA.SYSTEM-11NC.40UTLETS 6.00 property who builds or improves thereon, and who does such work himself or through his own employees. provided that shelf IlnprOVe- mentsarenotintendedoroffered for sale. If. however. the building 50. FT, FLOOR AREA TOTAL ACREAGE or improvement is sold within one year of completion, the owner builder will have the burden of pro pureeing that he did not build or im- - . GAS - EA. SYSTEM OVER 4 (EA.) 2.00 BUILDING USE prove for purpose of sale.). ❑ I, as owner of the property, ant exclusively contracting with RES IND CON Pe Omer ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 licensed contractors to Construct the project (Sec. 7044, Business and Professions Coda. The Contmclor's Liccnsc Luw does not apply ,to m1 owner of prnpetty who builds or improves thereon, and who contracts for such projects with a cuntractons) licensed pursuant to I he Commetois Lice ase Law. LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 ASSEsso ARCEL NO. ' LAWN SPRINKLERS- OVER 5 (EA.) 1.00 SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑ l .,It exempt under Sec. ,B.&P.C. for this reason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO, WATER TREATING EQUIP. 5.00 WORK ERS'COMPENSA'rION DECLARATION 1 hereby affirm that I havo a certificate of consent to w1hinsure, or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy thereof (Sec. 3800, Lab.CJ. , Policy No. Company 1 ❑ Certified copy is hereby furnished. ❑ Cerured Copy I. filed with the city inspeclion division. A"Ilicanl�.,,q}.� FIRE SPRINK Y❑ N❑ ENERGY T-24 Y❑ N❑ MISC.-REFER TO ORD. f�,,�, CERTIFICAT.0 XEMPTI i10\I WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.LU.C. ' COMPEN'WION INSURANCE (This action need not he completed it the permit is for one Y ❑ N ❑ Y ❑ N ❑ PLG.CONTR. LIC. NO.PEG TOTAL hundred dollars IS 100) or less.) I certify that in the performance of the work for which this per- ntit is issued. I shall not employ any person in any manner so as to OTV MECHANICAL PERMIT FEE , FEE SUMMARY become subject to the Workers' Compensation Laws of California. ALTER OR ADD TO MECH. 5.00 Dare Applicant BUILDING NOTICE TO APPLICAN"f: If, alter making this Certificate of Ex- APPLIANCE 5.00 j PLAN CHECK FEE n,nion,youshould Neu csuhiest to the Workers'Compcnsutiun provisions of the Labor Code, you muss forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT (TO 10MC.F.M.) 4.00 ` AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00 SEISMIC FEE S� CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 the per(annanee of the work for which this permit is issued (Sec. 3097, Civ.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address HEATING UNIT (OVER 100,000 B.T.U.) ELECTRIC VENTILATION FAN (SINGLE) 4.00 1 certify that I have ,ad fill, appiication and state that the above information is correct. I agree to comply with all lily Boll county ordinances and state laws elating to building construction, ami PLUMBING BOILER- COMP(3 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL hereby authorize roperty for ins of this City to corer upon the abuse ancntioned property for inspection purpous. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the grantingoflhis permit. 6 P�nq MISC.. REFER TO ORD. PERMIT ISSUANCE 10.00 CONST. TAX ' MECH. CONT. LIC. NO. MECH. TOTAL TOTAL a r coca r cto u c INSPECTOR COPY