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C8662 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8652 O E 'S PLAN CHECK VALIDATION NAME QTY. ELECTRIC PERMIT FEE PRorvB IVAme acroRs UTLETS-SWITCHES-RECEP 10.00/1.00 IC.No. IzJ17'3 LIGHTING FIXTURES 10.00/1.00 CONTRA To' PPLIANCES-RESIDENTIAL 4.00 • ADDRESS S HQ TJ6 Q I •� t._& vHONE p $p PANELS 10.00 - DATE OF APPLICATION ARC ITFCT - OR PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO. f ENGINEER ` LIC.No. SIGNS TRANS. 3.00 neo ESS SS SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP EMP.METER OR POLE INS. 20.00 APPucarurs - MOTORS SEE FEE SCH. ADDRESS OV\ • SERVICE CHANGE 20.00 wIt w o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 a o U 1 hereby affirm that I am licensed Under provisfmuof Chapter 9 ISSUANCE DATE yi (commencing with Section 7000)of Division 3 of the Business and a BN. ELECT. PLG. MECH. F m i Professions Code, . 1license i is in full force and effect. ❑ ❑ ❑ o Z w o Dale sc CI.,S?ei Lin.Number H m I- J Dame_ ontmmor o a r s BUILDING PERMIT F ¢o i OWNER-BUILDER DECLARATION' INFORMATION LL H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD H VALUATION $/FT. Fuoa Law for the following reason.(Se<.7031.5.Business Professions PERMIT ISSUANCE 10.00 Code:Any city or county which requires a permit to mnstrucL alteq Le improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. LL requires the applicant for such permit to file a signed statement that TOTAL _P5R w$ he is licensed pursuant to the provisions of the Contractor's License F Z 4 Law(Chapter 9(commencing with Section 7000)of Division 3 of the 2 4 D Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE I Ail SE H e the basis for the alleged exemption.Any violation of Section 7031.5 ST IES T PE CONSTR. -T. ie by any 11cre taN for a oodolsubjects S500).he applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 ' of not mom lhmt five hundred dollars(55007 J: ❑ I,as owner of the property,or my eniployces with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS their sole compensation,will do the work,and the St ructuru 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 TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such int Brow - menlsarenotintendedoroffered for sale.If,however,the holding GAS-EA.SVSTEM-11NC.40UTLETS 6.00 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 im- BUILDING USE prove for purpose ofsa1c.). INDUSTRIAL WASTE INTER. 30.00 E . IND CON PB Omer ❑ 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. 6.00ASSESSORS 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 contractons)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00 the Contractor's License Law. TRACT NO. PARCEL NO. ❑ I am exempt under Sec. ,B.&P.C.forthis WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00 I hereby uIG,. that I hove a certificate of consent to selfinsure, ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company O ❑ Certified copy is hereby'furnish-d. FIRE SPRINK ENERGY T-24 Z, O jp] Certified non is file vit he cit pemion division. MISC.- REFER TO ORD. Applcant Y N V N ~ va PERMIT ISSUANCE 10.00 � - f,:RTIPICATG 01:EXEMPTION('ROM WORKERS' FLOOD ZONE A.L.U.a. LU � ' COAIPHNSATION INSURANCE PLG.CONTR. LIC.NO. PLG. fL o (This Section need not be completed if the permit is for one TOTAL Y[:] N Y ❑ N Z hundred dollars IS 100)or less.) U O 1 certlly that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL H mit is issued,I shall not employ any person in any manner so as to 0U become Subject to the Workers'Compensation LawsMCaldornia. Date At licant t a 1 P ALTER OR ADD TO MECH. 5.00 BUILDING } y NOTICE' TO A should become If,after making this Certificate of Ex- emption,you the esubject muse Workers'Compensation APPLIANCE 5.00 PLAN CHECK provisions io the Labor Cit shall you must forthwith comply with FEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE 457) 1'sereby affirm that there is a construction lending agency]or EXHAUST HOOD (WITH DUCT) 5.00 the performance of Ore work for which this permit is issued(Sec. MICROFILM 3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's ess Name Lenders Nam HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00 information is correct. I agree to comply with all city and county PLUMBING oNinanees and state laws relating to huilding construction. and B6ILER-COMP(3H.P.or100,000B.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 pugroses. (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 way accrue against said Ci in consoquence of the PERMIT ISSUANCE 10.00 granting of this pcnnl MECH.CONT. LIC.NO. MECH. ( S TOTAL TOTAL r A plica onlractof' et INSPECTOR COPY