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C9423APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BEI LD1 NG PROJECT I DENTI FICATI ON APPLICATION & PERMIT BUILDING - ELECTRICAL -PLUMBING -MECHANICAL PERMIT NUMBER 9423 BOLDING noxa Ess CLp GA 1 47_1 T OWNER'S ryy NAME f / 44A>\ r ' _2,41 0k ' vaorfE' QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION f-/ V x 9'q/ "'r` NAME AcroI, OUTLETS-SWITCHES-RECEP 10.00/1.00 I LIC. No �/3 3 DATE OF APPLICATION LIGHTING FIXTURES 10.00/1.00 ADDRRAS oa'S CONTESp G. ^V PHONE%)3 Ir�C PPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 OORcmTEcr \ PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.c, No. ENGINEER. /C uc. No. i SIGNS TRANS. 3.00 ADDRESS Na. - SPECIAL CIRCUIT 5,00FCW.F PERMIT VALIDATION ZIP TEMP. METER OR POLE INS. 20.00 t ' IRI APPLICANT'S AOON EASS MOTORS " SEE FEE SCH."7J•% p/I v/(�� 0 0 SERVICE CHANGE 20.00 LICENSED CON' I' RACTORS DECLARATION TEMP. POLE 30.00 hereby affirm that I um licensed under provisions of Chapter 9 (conitncneing with Section 7000) of Division 3 of the holiness and Professions Code, and my license is in full force and effect License Class Lie. Number �..� Date���/��.��_� Contract Or ... ISSUANCE DATE BLDG. ELECT. © PLG. I MECH. IV 1 ❑ /-, -- / BUILDING PERMIT bW E N:R-BUILUEN DF-CLA O. I hereby ul'firm that I ant exempt fnml the Contractors License Law for the following reason. (Sec. 7031.5, Bisinessand ProfessionspERMIT Code: Any city Or county which requires a permit la construct. alter, Improve, de oolish, Or repair any structure, prior 10115 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 INFORMATION MISC. - y REFER TO ORD ISSUANCE 10.00 VALUATION S/FT. ELEC. CONTE. LIC. NO. ELEC. TOTAL PERMIT TO , OTY. PLUMBING PERMIT FEE Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of5ection 7031.5 by any applicant for a permit subjects lire applicant to a civil penalty of not more than five hundred dollars (S500)J= ALTER -DRAIN IEA.) 5.00 ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not BACK FLOW PROTECT. DEVICE 4.00 DCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, CONE). 5.00 intended or offered I'or sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to ml owner of FIXTURES - PER TRAP 5.00 Sll FT. FLOOR AREA TOTALACREAGE properly who builds or improves thereon, and who does Such work meritsfre not hrough ownemployees,fors,pnmfhowvded atsueh improve- meats are not intcndnl or offered for sale. If, however, the building `('""� GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00 _ or improvement is sold within one year of completion, the owner- builder sill have the burden of proving that he did not build or im- GAS - EA. SYSTEM - OVER 4 IEA.) 2.00 - BUILDING USE prove it purposenrsOlC'1' ❑ 1, as owner of the property, um exclusively eon lmcting with RES IND CON PB Other ❑ ❑ El C1 11 . . INDUSTRIAL WASTE INTER3000 licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law docs not apply to an owner of property who builds or improves thereon, and who LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.009!y ASSESSORS PARCEL NO. .3 7 .JI - t/ contracts fur such projects with a contraetons) licensed pursuant to the Contractor's License Law. - SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑ 1 and exempt under Sec ,B.&1'.C. Por mise r ... on ACC. DATE ACE. FILE NO, WATER HEATER W/VENT 6.00 Owner Dale WATER SYSTEM 5.00 - WATER TREATING EQUIP. 5.00 WORKFRS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self -insure. (it a certificate of Workers' Compensation Insumb", or u certified ZONING ENG. SITE N0. copy thereof (Sec 3500, Lab.CJ. Policy NCompany _,W" FIRE SPRINK Y[3 N� ENERGY T14 YE) NE] 13 Certified copy y f�eR46T_ ❑ Certified copy is filed with the city inspection division ,Applicant[[ MISC.- REFER TO ORD. CERT' F- GMPTIO FROM WORKERS' J "IrZo PERMIT ISSUANCE 10.00/,) FLOOD ZONE A.L.U.c. COMITNSA1'ION INSURANCE This Section need not be completed if the permit is for one PLG. CONTR. LIC. NO.PLG. I ��yy TOTAL p( & Y ❑ R Y [3 NEI hundred do]lars(S 100) Or less.) ' 1 certify that in the performance of the work for which this per-' mit is issued, I shall not employ any person in any manner s0 as to QTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING p/ UV -fa become subject to the Workers' Compersvtion Laws of California. Date Applicant NOTICE 'TO APPLICANT': If, after making this Certificate of E ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 PLAN CHECK eruption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT (TO I0=C.F.NL) 4.00 FEE AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm that mere is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 the performance of the work for which this permit is issued (Sec. 3097. Civ.C.). MICROFILM H EATING UN IT ITO 100.000 B.T.U.) 8.00 Lender's Nagle Lender's Address HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC �[ OV VENTILATION FAN (SINGLE) 4.00 I certify that l have read\Hiis application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws rcleting to building construction. and PLUMBINGy / d BOILER- COMP(3 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU( BEE FEE SCH. MECHANICAL hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. MISC.- REFER TO ORD. PERMIT ISSUANCE 10.00 CONST. TAX (We) agree to save; indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which m in any way accrue against said City in consequence of the I this permit. r Sig One MECH. CONT. LIC. NO. MECH. TOTAL TOTAL � � 7• +. ,.z.. INSPECTOR COPY