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C9286 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUI LDI NG PROJECT I DENTI FIC PERMIT NUMBER BUILDING APPLICATION & PEOT ADo Ess Rnh ILDING -ELECTRICAL-PLUMBING-MECHANICA 986 NAME OTYAN CHECK VALIDATION IAME . ELECTRIC PERMIT FEE ONE CONTRACTOR S UTLETS-SWITCHES-RECEP iQ00/1.00 N ME x % LIC.No. LIGHTING FIXTURES1Q.f10'1.00 riL CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00 ADDRESS PHONE - PANELS 10.00 DATE OF APPLICATION ARCH E PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No. OR / ENGINEER LIC.No, SIGNS TRANS. 3.00 ' AA CH OR GDDRESS ENG. SPECIALCIFICUIT 5,00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 APPLICANTS MOTORS SEE FEE SCH. ADDRESS SERVICE CHANGE 20.00 wo o LICENSED CONTRACTORS DECLARATION TEMP.POLE .k°.I 30.00 1/a Gv U 1 hereby affirm that l am licensed under provisions of Chapter 9 - 1 ISSUANCE DATE H a u (commencing with Section 70001 of Division 3 of the Business and G. ELECT. PLG. MECH. h-m Zz\ ,Professions Coda and_my license is in full fore an of t. z o w - License class_ �_Liu.Numbe © �- om H w Dmc Contractor m a ¢/ OWNER-BUILDER I>ECLA Rn'fION BUILDING PERMIT o eu D MISC.- REFER TO ORD INFORMATION X y I hereby collo that I am exempt from the Contractor's License LL0 < Law for the following reason.(Sec.703 L5.Business and Professions PERMIT ISSUANCE ��� VALUATION $/FT. � - 0 Code:Any city orcounty which rcquiresa permit toconstruct,alter, ¢ K G improve,demolish,or repair any structure,prior to its issmmce,also ELEC.CONTR. LIC.NO. ELEC. I' viiO ¢ requires the applicant for such permit to file a signed statement that TOTAL E MIT TO Es ro m he is licensed pursuant to the provisions of the Contractor's License R z >- Law(Chapter 9(commencing with Section 7000)of Division 3 oflhu g a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMITFEE1 F i n0 ac 0. the basis for tlie alleged ex emption.A ay via To l ion of Sec l i.n 7031.5 'I STORIES TYPE CONSTR, d ; 22 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00 of not more than five hundred dollars(55001.): ❑ I,as owner of lite property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS their sole compensation,will do the work,and the structure is not intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP5.00 as so.FT FLOOR AREA TOTAL ACREAGE himself of through his own employees.provided that such improve- GAS-EA.SYSTEM-1 INC.40UTLET$ 6.00 meats are not intended or offered for sale.If,however,the building sL or improvement is sold within one year of completion, the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 builder will have the burden of proving that he did not build or inn BUILDING USE prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 R IND CON PB Omer �. ❑ 1,as owner of lire property,am exclusively contracting with ❑ ❑ ❑ ❑ licensed contract., to corlstnmt the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6 O ASSESSORS PARCEL NO. and Professions Code:The Contractor's License Law does not apply �t to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OV ER 5(EA.) 1. 0 1 contracts I'or such projects with a contractors)licensed pursuant to { the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. 5. ❑ I mnoxempt under Sec. ,B.&P.C.I'or this - WATER HEATER W/VENT 6.00 t4 reason ( Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORSERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hemby atfirm Thal I have a certificate nl'conSent to salGmsur,, - .. \ ' or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE N0. /y` copy lher f Sec 3 L C.). I Policy N D-Ce I c her d k FIRE SPRINK ENERGY T-24 ❑ C'enil'ic' y IT it Ci• ec dmsion' MISC.- REFER TO ORD.Z p Applicant Y ❑ N❑ Y ❑ N❑ 1; ~ir rn -i PERMIT ISSUANCE 10.00 (� LU 1 f'LN7IFICCOI�P[N$AT[ONEX NPI IINSURAON UNCHNI D K $ PLG.CONTR. LIC.NO. PLG / FL000 ZONE A.LU.C. V N V C] N Z hundred section need not be completed if lire pennil is for one TOTAL f1T/ ❑ ❑ ❑ hundred doll:us(S 100)or IessJ U O 1 certify that in the performance of the work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY UL I- mit is issued,1 shall not employ any person in any manner so as to j 0U become subject to the Workers'Cnmpensafio..Laws of Culil'mnia. r BUILDING Ta- Dule APphc?nt LTER OR ADD TO MECH. 5.00 } In NOTICE TO APPLICANT: If,after making this Certificate of Es F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK Ill provisions of the Labor Code, you must forthwith comply with J U such p,.visions or this pennil shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00 FEE I� CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE Ie, 1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 lire performance of the work for which this permit is issued(Sec. MICROFILM 3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Addle HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC -76"a ss ' 1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 ,formation is correct. I agree to comply with all city and county PLUMBING (� :`• ordinances and Slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 .. herebv authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL m �) above- entioned property for inspection purposes_ }1 (We) agmc to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 1000 CONST.TAX may in any way accrue against said City in consequence of the . it At pe it MECH.CONT. LIC.No. MECH. ^ / TOTAL I' )'on actor ate -- /.S-x TOTAL /�6 INSPECTOR COPY -`"N