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7079 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER BUILDING APPLICATION & PERMIT Q ApOREss n/A� n04L1 ,5KAnnrt4 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7079 OWNER'S �/ % L. 'WJWCN` PLAN CHECK VALIDATION NAME • -TrDi 14 I PHONE hTY. ELECTRIC PERMIT FEE J J CONTRACTORS MOUTLETS-SWITCHES-RECEP 5-00/1.00 NAE uC.NO, U LIGHTING FIXTURES 5.00/1.00 CONTRACTOR'S 77U eN6ST.tJ�JT� PPLIANCES-RESIDENTIAL 4,00 ADDRESS PHON PANELS 5.00 DATE OF APPLICATION OR RCHIT EC SIGNS 6.00 PLAN CHECK FEE P.C.NO. O ENGINEER uc.No. SIGNS TRANS. 3.00 ADDRRESS ENG' SPECIALCIRCUIT 5.00 PERMIT VALIDATION ZIP rrEMP. METER OR POLE INS. 15.00 Ai'S ADDRESS MOTORS SEE FEE SCH. f ADDRESS SERVICE CHANGE 10.00 S/ Dei r D a LICENSED CONTRACTORS DECLARATION u I hereby affirm that I am licensed under provisions it Chapter 9 ISSUANCE DATE a z w (c'ommencing with Section 7000)of Division 3 of the Rosiness and BLDG. ELECT. PLG. MECH. o w z 1•ro(essions Code.�nd y license is in full force' d ef(e .� ❑ ❑ ❑ ©\ z o u,- Lions:Cl .I Number L z Date----/ Convactar�/}.j�_-- a rf .'+ BUILDING PERMIT a BEw OWNER-BUILDER DECLARATION INFORMATION seO d N 1 herebyeftlnn that I am exempt from the Contractor's License MISC.- REFER TO ORD u h P Businessand Pride...ops VALUATION H_ o Loa for me Following•:mon.(Sec,703 L5. PERMIT ISSUANCE 6.00 Code Any city or county which requires a permit to construct,alter. Qu,Q 0 Improve,demolish,Or repair any structure,prior to Its issuance,also ELEC.CONTE. LIC.NO. ELEC. D Q requires the applicant for Such permit to file.signed statement that TOTAL PERMIT TO u w m u. he is licensed Pomxl:ot to the provisions of the Contractor's License Hzi Law(Chapter 9(commencingwith Section 7000)ol-Division 3o film L� F 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE I-o the basis for the alleged exemption.Any violation r(Sectim.7031.5 STORIES TYPE CONSTR. by any applicant lin a permit subjects the applicant to a civil penally ALTER-DRAIN IT,VENT-WATER (EA.) 4.00 of not more than five hundred dollar(S50N.): ❑ I,as owner of the pmperty,or my employees with wages as BACK FLOW PROTECT. DEVICE their sole compensation,will do the work,and the structure is not 2-00 OCC.GROUP RES.UNITS intended or offered for Sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 Code: I lie Contractors License Law dons not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE . himself or through his own employees,provided[fiat such improve- -EA.SYSTEM-11NC.40UTLETB 4.00 :crus are not intended or offered for sale.If,however,the building GAS r Improvement is sold within one year of completion,the owner GAS-EASYSTEM-OVER 4 IEA) 100 BUILDING USE builder will have the burden of proving that he did not build or im . . . RES IND CON PB OtM1er prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ 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. 5.00 ASSESSORS PARCEL NO. and Nobc,sions Code:'I'lie Contractor's License Law docs 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 contractorls)licensed pursuant to the Con tractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO. ❑ Imo exempt under Sec. ,B.&I•.C.fur alis WATER HEATER W/VENT 4,00 I reason Owner _ Dare WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO. m - WORKERS'COMPENSA"PION DECLARA'I'[ON WATER TREATING EQUIP. 4.00 I hereby ART. that 1 lave a certificate of consent to self-insure. ZONING ENG.SITE NO. or a ceRificaue of Workers Compensation Iruulnce,or a certified copy thereof(Sec.3800,Iab.C.). /�/� Policy Nn..G(/La mnpatty FN.1 12R'o ❑ Certified ty is hereby fur rshed. FIRE SPRINK ENERGY T 24 C✓Certified r ff��11 flet the//��I��' �mfsfection division. MISC.- REFER TO ORD. z O Applicant_, ^ 1C..L IC-�11(a Y ❑ N❑ Y ❑ N❑ .ir rn CER'FIFICA'TE 01'Ii Xf MPAION FROM WORM RS' PERMIT ISSUANCE 6.00 FLOOD ZONE .AL.0 c. LL COMPFNSAT10N INSURANCE PLG.CORER. LIC.NO. PLG. v❑ N❑ Y El N❑ Z ('this section Iced not he completed if ore permit is for one TOTAL IT mid Tell dollars IS 100)nr lea.) U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY LL F mit n issued,I shall not employ any person in any manner so as to U become subject In the Wmkers'Co.. omsation laws.(California, BUILDING a Dale-Applicant ALTER OR ADD TO MECH. 4.00 } N NOTICE 'TO AITLICAN'1': Ir,after nuking alis Certificate of Ex 2 cmption,YOII should beconm subject to the Workers Conmpcosation APPLIANCE 4.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CF.M.) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 5.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 the performance of the work for which this permit is issued(sec. MICROFILM 3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 All 6)A Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50 Lender's Name ELECTRIC I.� certify abut I""c mal this aPp""Hiou and state that be above VENTILATION FAN (SINGLE) 3.00 orinformation is crect. I agree to comply with all City and county PLUMBING ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL 0 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 PERMIT ISSUANCE 3.00 CONST.TAX may ir(any way a rue against slid City in consequence of the I SON iirlgµhf 1h IS pen h MECH.CONT. LIC.NO. MECH. �\\ t\y JI J/�J, 4 p�/r p E/� µI {{) a TOTAL Smgdan of vC Phe nt C)ntrael� /pal 1 0.5 /J Ir'// //t?1raU4g o�'J4Db 7 00 TOTAL O� I INSPECTOR COPY