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7170 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTI FICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT ADDRESS 101000rjI De 407'a BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 7170 OWNER'SPLAN CHECK VALIDATION NAME - QTY. ELECTR IC PERMIT FEE • 0-0.COS. PHONE CONTHACTOHS \/ I�f ✓iw'. OUTLETS-SWITCHES-RECEP 5.00/1.00 NAME V (�jLXrc/ UC.NO. 7,41 IGHTING FIXTURES 5.00/1.00 219 CONTRACTOR S PPLIANCES-RESIDENTIAL 4.00 ADDRESS �pp �IZ,pr• PHONE PANELSi 5.00 DATE OF APPLICATION .ARCHITECTSIGNS M1 6.DU PLAN CHECK FEE P.C.NO. OH EN EER LIC..O. SIGNS TRANS. 3.00 O ARCH.OR G.0OO r"o SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ADDRESS "" ���.�`y.'� G��j/' 11 I ... Sac 14EMP.METER OR POLE INS. 15.00 ,C�I,y1 ADORESNrs 'y �'�"Yr MOTORS SEE FEE SCH. ADDRESS '^A r 4v yl UI W SERVICE CHANGE a wo o hICENSEU CONTRACTORS UGCLARATION <u u I hereby affirm that I am licensed under provisions of Chapter 9 _ _ / ISSUANCE DATE w<m (commencing with Section 7000)of Division 3 of the Business and / BLDG. ELECT. PLG, MECH. F n In Professions Code,and n IICen�C is in full force ur1J7f e / ❑ © ❑ O z o m- hiwnse Cla's I Lic.Number O ro Dntc Con[actor ✓�'/� a`y s � /' G T 471- BUILDING PERMIT ¢ ¢w¢ OWNER-BIIILDER DECLARATION INFORMATION A old" MISC.- REFER TO ORD w Olt y I hereby affirm that I am exempt from the Contractor's License VALUATION S/FT. u.O,4s Law for the lbllowing reason,(Sec.703 L5,Business and Professions PERMIT ISSUANCE 6.00 Code Any city orcounty whichreyuiresapennil to Construct,alter, �yy ¢ K Q Q• Iimprove,demolish,or,c,U any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC./ �• 0 LL rcyuires Ibe applicant fm sigh permit to file a signed slaRmenl Thal TOTA PERMIT TO asmhe.is licensed pursuant to Ihe,provisions of the Contractor's License H z a Law(Chapter9(commencing with Section 7000)of Division 3 ofthe E�Ga7 Business and Professions Code)or that Be is exempt therefrom and CITY. PLUMBING PERMIT FEE ¢ r o the basis for the alleged exemption?Any violation of Section 7031.5 STORIES TYPE CONSTR. y if° byallyapplicant for.permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 Occ.GROUP RES.UNITS thm (licit sole compensation,will do the work,and the structure is not intended or offered for sale (Sce. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 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 TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE • himself(it through his own employees,provided that such improve- ments are not intended ofoffered for sale.Il',however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00 or improvenienl is sold within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BuaOwG USE builder will have the burden of proving Drat he did not build ori nt- - RES IND - CON Pe Omer prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ 1,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 Professions Code-"I'he Contractor's License Law does not apply to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5'IEA.) 1.00 contracts for such projects with a contracions)licensed pursuant to the Contractors License Law. I SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO. ❑ ImGcxemptunder SeC. .B.&P.C.for this WATER HEATER W/VENT 4.00 mason Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO. WORK ERS'COM PENSATION DECLARATION WATER TREATING EQUIP. 4.00 I hereby infirm that I hove a certificate of consent tosell'-insure, BONING or u certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO. copy thereof(Sc'�.3 0-Lub.C.) RIL G Policy No npany� Q ❑ Certified Copy is hereby furnished FIRE SPRINK ENERGY T 24 q�� Certified o y is filed w th he city sec Con i Zp A(iplicant Ul�pis �I�/'- j[-aylct A-v ( , MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑ Cr CI:R'I'[FICA TCOI EXEMPT ON 1'RON wORKIiRS' 1 PERMIT ISSUANCE 6.00 FLOOD ZONE ALOG. c. L �_ COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLG. CL 0 ('this section need not be completed if file permit is for One TOTAL Y❑ N❑ Y F] N[ z hundred dollars IS 100)or less.) . U 0 1 Certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY LL I- mit is issued,I shall not employ any person in any manner so as to U become subject m the Workers'Compensolion Laws of California. U a Dale Applicant ALTER OR ADD TO MECH. 4,00 BUILDING } b NOTICE 10 APPLICANT: if,after making this CertifcotcoLEx- (_ Z emption,you should become subject to the Workers Compensation 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=C.F.M.) 3.00 CONST'RUCI'[ON LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE I hereby ul'firni Ihut 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. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM 3097, s Na). a Lender's Name Lender's Address s HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC U 1 certify'shut 1 have read this application and state that Die above• VENTILATION FAN (SINGLE) 3.00 information is correct. I agree to comply with all city and county PLUMBING Irrdine L and slam lows rchitiny in building construction, and BOILER-COMP Q H.P.or 100,000 B.T.U.) 4.00 creby authorize representatives of this city.to enter upon the BOILER-COMP IovPr 100.000BTU)SEE FEESCH. MECHANICAL above-nienlioned properly for inspection purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, cuss and expenses whichCONST.TAX may in any way accrue against sid City in consequence of the PERMIT'ISSUANCE 3.00 granI got lhix per I. MECH,CONT. LIC.NO. MECH. z ..S TOTAL TOTAL S a aro 'A p cant ontrac or r Dale INSPECTOR COPY