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C6018 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY .- BUILDING PROJECT IDENTIFICATION PERMIT NUMBER APPLICATION & PERMIT' B°"°'"° 6018 ADDRESS b O A BUILDING-,ELECTRICAL-PLUMBING-MECHANICAL OWNER' L - • PLAN CHECK VALIDATION "AME // OTY. ELECTRIC PERMIT FEE C (.14� VHONEj� croRs NAME OUTLETS-SWITCHES-RECEP 5.00/1.00 NAMEpp x. 'PV (-b JI LIC.NO./? 7/ LIGHTING FIXTURES 5.00/1.00 CONTRACTORS APPLIANCES-RESIDENTIAL 4.00 ADDRESS eHONESr PANELS 5.00 DATE OF APPLICATION AROHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO. OR ENGINEER uc.No. SIGNS TRANS. 3.00 ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION zIP EMP.METER OR POLE INS. 15.00 , �r ASMOTORS SEE FEE SCH. ADDRESS ADUR SERVICE CHANGE 10.00 o o LICIiNSEO CONTRACTORS DIICLARA'fION < U P: I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE yw (commencing with Section 7000)of Division 3 of the Business aid ¢ a BLpG. ELECT. PLG. MECH. F N i Professions"u and n y license is N full force and effect. ❑ ❑ ❑ ' 0.- License C ss - Lic.Number/7 727/ r O � F � (lute Contractor©.c. abr ¢ Y E BUILDING PERMIT OWNER-BUILDER DECLARATION INFORMATION OnMISC.- REFER TO ORD E: 3 u r I hereby aolnn Incl I am exempt from the inessContractor's License VALUATION $/FT. F u_O j Law for the hollowing reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00 tN > E Code:Any city or county which requiresa permit loconstruct,alter. ELEC.CONTR. LIG NO. (¢ a D improve,demolish,or repair any structure,prior to its issuance,ulsn ELEC. i iL M , requires tiro applicant for such permit to file a signed statement that TOTAL PERMIT TO w mu. i he is licensed pursuant to Ilio provisions of the Contractor's License �L R, z Law(Chapter 9(commencing with Section 7000)of Division 3 of tire x ao Business and Professions Code)or net he is exempt therefrom and' QTY. PLUMBING PERMIT FEE ¢ I- o the basis in,the alleged exemption.Any violation of-Section 7031.5 STORIES TYPE CONSTR. ate _ by any applicant for a pcumit subjects the applicant o a civil penalty ALTER-DRAIN&VENT-WATER'(EA.) 4.00 - of riot more than five hundred dollars(SS00).): ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS their sole compensation,will do the work,and the structure Is not intended or offered for sato(SCC. 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 or through his own employees,provided that such improve- mentsarenotintendedoroffered for sale.If however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM.OVER 4 IEA.) 1.00 BUILDING USE builder will huve the buNen of proving that he did not build or im- RES IND CON PB Omer prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 O 1,as owner of the property,urn exclusively contracting with licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. ,r 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 conlraclots)licensed pursuant 10 one Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO. O Ism exempt under Sec. ,B.&P.C.fill this WATER HEATER W/VENT 4.00 reason Owner Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO. WORK ERS'COMPRNSA""PION DECLARATION WATER TREATING EQUIP. 4.00 1 hereby atGrm that I have a certificate of consent to sell'-insure. ZONING ENG.SITE NO. or `vnificmC Workers'Cnm rensalion Insurance,nr u certifiedd copy ulerc 1(se Do.Lan.r..I!11 Policy No. Company - �, O ❑ Certified rllT copy is hereby furrrrr1117ied._ _ FIRE SPRINK ENERGY T 24 Z 2 Ufied copy is tiled with oe city inspection division. MISC.- REFER TO ORD. Q llcanl Y NE] , Y [:] NE] CC T CIi RI'IFICA'1'17 OF EXI MI'1'ION FROM WORKERS' PERMIT ISSUANCE 6.00 6 FLOOD ZONE A.L.U.C. W > COMPF,NSWION INSURANCE; PLG.CONTR. LIC.NO. PLG. 0. O (Phis section need not he completed if the permit is for one •e. 44 4 711 TOTAL �� Y❑ N� Y E] NEI Z) 2 hundred dullars($100)or less.) . V 0 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY W F• mit is issued,I shall not employ any person in any manner so un to U becmne subject to the W'orkels nl Copensption Laws of California. V Lu Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING >_ m NCOICE '10 APPLICANT': If,after making this Certificate of Ex- F ? ,minion,you should become subject In the Workers'Compensation APPLIANCE 4.00 PLAN CHECK provisions of the labor Code, you must forthwith comply with FEE 1 V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 CONSTRUCTION LRNDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 5.00 SEISMIC FEE I hereby uffin r that there is a Construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 the periormance of the work for which this permit is issued(Sec. MICROFILM 3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lender's Name Lender's Address HEATI NG UN IT(OV E R 100,000 B.T.U.)7.50 ELECTRIC 1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 n fornalion is correct. 1 agree to comply with all city and comfy PLUMBING •I BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 oNinances and stale laws relating m building construction, and hemhy aullnuice representatives of this city to enter upon Id BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property for inspection purposes. (We) agree In save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against Iiuhilitict,judgmmuts, costs and expanses which PERMIT ISSUANCE 3.00 CONST.TAX may in any way accrue against said City in conseyuencc ol'Ihe gin ti of this pent lL MECH.CONT. LIC.NO. MECH. //� 2 TOTAL TOTAL j Si rare of Applicant/Contractor Date 1 1 /O INSPECTOR COPY