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8492 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU I LDING PROJECT IDENTIFICATION PERMITNUMBER BUILDING APPLICATION & PERMIT ADDRESS BUILDING-ELECTRICAL-PLUMBING -MECHANICAL f OWNE 'S PLAN CHECK VALIDATION NAME QTY. ELECTRIC PERMIT FEE ® PMONE NAMER crD OUTLETS-SWITCHES-RECEP 10.00/1.00 LIC... ILIGHTING FIXTURES 10.00/1.00 cD 'S APPLIANCES-RESIDENTIAL 4.00 A KESS _ ��/ VNONE _ PANELS .10d7D DATE OF APPLICATION oa T PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.c,No. ENGINEER LIC.NO. SIGNS TRANS. 3.00 ADDRESS ENG. PERMIT CIRCUIT 5.00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 APPLICANTS ADDDRESSDRESSMOTORS SEE FEE SCH. SERVICE CHANGE 20,00 'yg ,f '09 LICENSED CONTRACTORS DECLARATION TEMP.POLE s 30.00 /oil a v I hereby affirm that I am licensed under provisions of Chapter 9 _ ISSUANCE DATE i7 G c (commencing with Section 7000)of Division 3 of the Business and �.. BLDG. ELECT. PLG. MECH. F N y Professions Code,and my license is in full force and effect ❑ © ❑ ❑ o i m W License Class Lie Number ti DmeContrador ei x /.L7R: BUILDING PERMIT ¢ S,w ¢ OWNER-BUILDER DECLARATION G O> INFORMATION X g w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD vy r cc o < Law for the following reason.(Sec.7031.5.Buxiocssand Professions PERMIT ISSUANCE VALUATION $/FT. Code:Any city or county which requires a penmt m construd,alRq 0 ¢¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. 1 - A wD¢ requires the applicant for such permit to file a signed statement that 1 ? TOTAL •• PERMIT TO m w he is licensed pursuant to the provisions of the Contractor's License r ur Law(Chapter9(commencing with Section 7000)of Division 3 ofthe Ir io Business and Podessions Code)or that he is exempt thercfnnn and OTY. PLUMBING PERMIT FEE - L LCA Y• �'� It r Its the basis for the alleged excoriation.Any violation ul Section 7031.5 STORIES TYPE CO TR. nam by any applicant for a pemhit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars(SS00)J: ❑ I,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 tin work,and the structure is not intended or inhered 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 improve - mentsarenotintendedorofferedforsale.It,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 or improvement is sold within one year Of completion, the owner- ba wner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 builder will have the burden of proving that Ile did not built)or int- BUILDING USE prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB ane, w ❑ 1,as on . . owner of the property,am exclusively contracting with ❑ ❑ ❑ 0 ❑ licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL N0. 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 u contruelons)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00 the Contractor's 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 N0. WORK ERS'COMPENSA'FION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that 1 have a certificate Ofconsent to self-insure. or a certificate of Workers'Compensation Insurance,or a certified - ZONING ENG.SITE NO. copy thereof(See.3900,Lab.C.1. + Policy Nn. Company O ❑ Cartifwd copy is hereby tum shed FIRE SPRINK ENERGY T 24 z Z � Certified copy is fled with rte cdy inspection division. - ❑ ❑ ❑ ❑ O Applicant x MISC.- REFER TO ORD. Y N V N CC w CERT&4C\TE OF EXESIPT10N FROM WORKERS' PERMIT ISSUANCE 10.00 PLOODZONE A.L.U.C. W > COh1PENSATION INSURANCE PLG.CONTE. LSC.No. PLG. - CL 0 1'1'his section need not be completed it the perinil is for one TOTAL V❑ N� Y[:] N� hundred dollars IS 100)or less.) U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY LL U mit is issued,1•sha11 not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California. �'d Dane Applicant BUILDING >_ W NO'T'ICE*TO APPLICANT': If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 F Z emptloa,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 10=C.F.M,) 4.00 CONSTRUC'1'ION LENDING AGENCY AIR HANDLING UNIT OVER I0,000C.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 the work for which this permit is issued(Sec. MICROFILM 3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 Lenders Address ELECTRIC S� � 1 cerlify that I have read this application and stain that the above V ENTI LATION FAN (SINGLE) 4.00 • information n correct I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING ordinances and state laws relating to building construction, and hereby authorize representatives of this city to en Rr upon the 8011.E R-COMP(Over t00,0008TU15EE FEE SCH. MECHANICAL abovomentioned property for inspection purposes. (We) agree to save, indenmify and keep harmless the City ofMISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which CONST.TAX may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 10.00 gra ng of this permit MECH.CONT. LIQ NO. - MECM. TOTAL TOTAL S aturc p a C ntmc Or ht INSPECTOR COPY