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9246 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENT[FI CATION PERMIT NUMBER BUILDING APPLICATION & PERMIT 9Z 46 1 ADDRESS qAve BUILDING-ELECTRICAL-PLUMBING -MECHANICAL OWNER'S - PLAN CHECK VALIDATION NAME (r�(f_[� I� Q QTY. ELECTRIC PERMIT FEE N 1 C t l SPHONE L��Oz f NOMEEAcross 1. OUTLETS-SWITCHES-RECEP 10.00/1.00 uc.NO. LIGHTING FIXTURES 10.00/1.00 CONTRASDDRESS DFs AAPPLIANCES-RESIDENTIAL 4.00 PHONE PANELS 10.00 DATE OF APPLICATION ARCHITECT - - PANELS (OVER 200 AMP) 20.00 PLAN CHECK fEE P.C.NO. OR ENGINEER uc.Na. SIGNS TRANS. 3.00 ARCH. DD EBS ENG. SPECIALCIRCUIT 5,00 - PERMIT VALIDATION ZIP - EMP.METER OR POLE INS. 20.00 q APPLICANT MOTORS SEE FEE SCH. 54 R /V'•'•••✓ ADDRESS � Ate` SERVICE CHANGE 20.00 '00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 u o 1 hereby affirm that I ant licensed under provisions of Chapter 9 ISSUANCE DATE Na vwai (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. z Professions Code,and my license is in full force and effect. 20 o - License Class Lic.Number- 0 El 1:10 z r w Date-Contractor Yf BUILDING PERMIT CE o a D OWNER-BUILDER DECLARATION INFORMATION 3 w I- 1 hereby affrci that I am exempt from the Contractor's License MISC.- REFER TO ORD u ,A VALUATION H u o J Law for the following reason.(Sec,7031.5,Business and Professions PERMIT ISSUANCE 10.{10 (}O Cotte:Any city or county which requires a permit to construct,alter, M ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. as O an requires the applicant for such permit to file a signed statement that TOTAL w m u he is licensed pursuant u,the provisions of the Contractors License TO's License `� \ H z i Law(Chapter9(commencing with Section 7000)of Division3of the ,q a Business and Professions Code)or that he is exempt therefrom and GTV. PLUMBING PERMIT FEE Lothe basis for the alleged exenlptiom Any violation of Section 7031.5 STORIES TYPE CONSTR. Lo by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars(5500).): A1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCG GROUP RES.UNITS sole compensation,will do the work,and the structure is not intended or.offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CONE. 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 TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 CC improvement Is sold within one year of completion. - .the owner- GAS EASYSTEM-OVER 4 (EA.) 2.00 BUILDING USE builder will have the burden of proving that he did not build or fill- HES IND CON PB Omer prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ I,as owner of the property,mil exclusively contacting with ❑ ❑ El El 1:1 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 does 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 contramor(s)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ I am exempt Ruder Sec. ,E.&P.C.ferillis WATER HEATER W/VENT 6.00 on owner t WATER SYSTEM. 5.00 ACC.DATE ACC.FILE NO. WORK FRS•COMPENSATION DECLARA WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent to scl6in.Lire, ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO. copy theaaf(SCo.3800,Lub.C.). Policy No. Company O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24 Z Z ❑ Certified copy is tiled with the City inspection division. O Applicant MISC.- REFER TO ORD. Y ❑ N Y ❑ NE] CC y CERT IEICA'I'li OP EXF-MPI']ON FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 U.C. W COMPENSATION INSURANCE PLG.CONTR. ED.NO. PLG. NNE] Y NE] 0 (This section need not be completed if Itle permit is for one TTOAL Y hundred dollars($100)or IessJ U O 1 certify that in the performance of the work for which this per- GTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued.1 shall not employ any person in any manner so as to O become subject to the Workers'Compensation Laws of California. LEI Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } to NO"DICE '10 APPLICAN f: IL after staking this Certificate Of Ex- Z emption,you should become subject to the Workers'Compensation 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 100WC.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10JMC.F.M.) 6.00 SEISMIC FEE I hereby affirm that there is a Construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 the performance of Om work for which this permit is issued(Sec MICROFILM 3097,Cr,C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Andre H EATING UNIT(OV ER 100,000 B.T.U.)9.50 Lender's Address ELECTRIC I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.0.0 information is correct. 1 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.) 6.00 hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL 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 cxpensiw which PERMIT ISSUANCE 10.00 CONST.TAX may in any way cru. against said City in consequ toe tfyk g tm d t pen L b t MECH.CONT. LIC.NO. MECH. O 1 TOTAL �� tiAto - TOTAL Signature of Applicant/Contractor Date INSPECTOR COPY