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8461 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER APPLICATION & PERMIT ADDR l� BUILDESS C�ING #1 /. 1 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL8461 NAME S n�r�� ((--�1'' PLAN CHECK VALIDATION ,( 'mac QTY. ELECTRIC PERMIT FEE PIFINF NAME GENITT[AGI°al UTLETS-SWITCHES-RECEP 10.00/1.00 r-. G uc.No. LIGHTING FIXTURES 10.00/1.00 1 ' C,ONTRACTCR ADDRESS APPLIANCES-RESIDENTIAL 4.00 AD PHoivE PANELS 10.00 DnrB OF APPLICATION AC T T PANELS (OVER 200 AMP) 26.06 PLAN CHECK FEE '� P.C.NO. OR ENGINEER LIE.No. SIGNS TRANS. 3.00 ADDRESS ENG. PERMIT VALIDATION ADDREss SPECIAL CIRCUIT 5.00 ZIP TEMP. METER OR POLE INS. 20.00 ADDREss TS MOTORS SEE FEE SCH. l SERVICE CHANGE 20.00 F o o, LICENSED CON TRACTORS DECLARATION TEMP, POLE 30.00 ¢ v . 1 hereby affirm 0mt I am licensed under provisions ol'Chapter 9 ISSUANCE DATE mZ u, (commencing with Section 7000)of Division 3 of the Business and , Q H BLDG. ELECT. PLG. MECH. E, o Z Prolessions Code,and my license is in full force and effect � y o m- License Clue Lie.Number T:1 �Z � LS:P o Z o Pate Contractor a y �� BUILDING PERMIT ¢ ¢o u a OWNER-BUILDER DECLARA'CIOR INFORMATION veg LL r I hereby affirm that I am ex,mpl Cmm the Contractor's License MISC.-I REFER TO ORD vgwnnoN FLo¢ Law for the following ,area (See 7031.5.Business and Professions PERMIT-ISSUANCE 10. 0 Code:Any city or county which requires u permit to construct,alter, LE u ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ca 0 ¢ requires the applicant forsuch permit to file a signed statement that TOTAL a wLe he is licensed pursuant to the provisions of the Contractor's License PERMIT TO H Z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe �� 4 er Business and Professions Code)or that he is exempt therefrom and QTY- PLUMBING PERMIT FEE ¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. a3e� 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($500)J'. ❑ 1,as owner of the property,or my employees with wages as - BACK FLOW PROTECT:DEVICE 4.00 OCC.GROUP RES.UNITS their sole compensation,will do the work,and the structure is not intended or offered for .in IS". 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 1 Code The Contractor's License Law does not apply to an owner of property who builds on improves thereon,and who does such work FIXTURES-PER TRAP 5.00 S°,FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such intprove - meritsarenotintendedoroffered for safe.IL however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE builder will have the burden of proving that he did not build or int prove for'purpose of sale,)' INDUSTRIAL WASTE INTER. 30.00 RES IND CON 'PB Due, ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B- 6.00 ASSESSORS PARCEL NO. and Professions Code:The Contractor's License Law docs not apply to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a cont uctons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 the Contractors License Law. TRACT NO. PARCEL NO. ❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE No, WORK17RSCOMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified copythcreof(Sec.3800 LmC) T Rainey No. Company ytYg�yr$ 1CU Certified copy is hereby",.rn FIRESPRINK ENERGYT24 1 Z 2 ❑ Certified copy is tD,riled with the city inspection division. FO Applicant r ?02.7 O MISC- REFER TO ORD. Y ❑ N❑ Y IN � N CE:RTIFICATIi OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. W > COMPENSATION.INSURANCE PLG.CONTE. LIC.N0. PLG. ❑ N❑ Y❑ N❑ EL O This rection need not be completed if tile Ye permit is for one TOTAL :DZ hundred dull ars($100)or less U O.. 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued,I shall not employ any person in any manner so as to U W become subject to the Workers'Compensation Laws(if California. d. Date - Applicant ALTER OR ADD TO MECH. 5.00 BUILDING >_ to NOTICE TO APPLICANT: If,after making this Certificate of Ex- F- 2 enlption,you should become subject to the Workers'Compenmtion APPLIANCE 5.00 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=CF.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE 1 hereby affirm thal tire',is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 Ila-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's Name Lender's Address HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC �. I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 information is correct I agree to comply with all city and,minty PLUMBING ordinances and state laws relating to building construction. and BOILER-COMP(3 H.P.cur 100,000 B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100.000RTu1SEE FEESCH. MECHANICAL above-mentioned property for inspection purpose. (We) agree to save, indemnify and keep harmless the City of MISC.- - REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which CONST.TAX may in any I way accrue against��,kid City in consequence of the PERMIT ISSUANCE 10.00 grun'ingof rmit. MECH.CONT. LIC.NO. MECH )-- 1 .J� . r5- TOTAL TOTAL SigPaturcoI7AppHcamlfContfnRSpI 'Date, - f INSPECTOR COPY