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12954 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 1 BUILDING PROJECT I DENTI FICATION PERMIT NUMBER - - BUILDING APPLICATION & PERMIT ADDRESS Z �3 �r, BUILDING- ELECTRICAL-PLUMBING-MECHANICAL LL 12954 OWNER'S PLAN CHECK VALIDATION 74 NAME qj Pb OTY. ELECTRIC PERMIT FEE //`4 O f O PHONE G-. YJC CONTRACTOR'S UTLETS-SWITCHES-RECEP 10.00/1.00 16 NAME L,C.N y 3 3 ,-4 LIGHTING FIXTURES 10,00/1.00 c0NTRACTORS - PPLIANCES-RESIDENTIAL 4.00 - AODP��E5jj5 N.�Ur�JJ'' ?vl JS+7JRAT0 DA-PHONE 14.4Ce_S74G PANELS 10.00 DATE OF APPLICATION ARCHITECTPANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO. OR ENGINEER - " LICNO SIGNS TRANS. 3.00 ARCH.OR ENG. - SPECIAL CIRCUIT 5,00 PERMIT VALIDATION ADDRESSLIGAN ZIP EMP.METER OR POLE INS 20.00 ADDRESS MOTORS E FEE SCH. ADDRESS ,f SERVICE CHANGE 20.00 o O LICENSED CONTRACTORS DECLARATION MAY b ' a o U I hereby affirm that I am liiensed under provisions of Chapter 9 ISSUANCE DATE 'I' CRY w ection 7 Divi I of the Business anJ F n (commencing 7th$ 000)O( I son 3 BLDG. ELECT. PLG. MECH: way w Professions Code,an y license is in full force e 3 ❑ fwl H u2 I"Y-'Il I`tY'1` L�J o i m RX License CI s Con Number _ "� Date Contractor a x f a BUILDING PERMIT ¢ ¢ ,¢ er OWNER-BUILDER DECLARATION INFORMATION w0aADMISC.- REFER TO ORD 3 _ 1 hereby affirm that 1 amiexempt from the Contractor's License VALUATION $/FT. F u o a Ia Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00416 Code:Any city or county which requires a permit to construct,alter, 2a,G p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.'NO. ELEC. o ¢ requires the applicant for such permit to file a signed statement that TOTAL �� ,/� PERMIT TO n w m¢ he is licensed pursuant to the provisions of the Contractor's License AvJ�aj Law(Chapter 9(commencing with Section 7000)ofDivision 3 olthc / a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE ¢ o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. n ;m by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00 of not more than five hundred dollars(S500).): ❑ 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 the work,and the structure is not intendeOor 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 SQ FT.FLOOR AREA TOTALACREAGE himself re through his own employees,provided that such improve. prones are not intended or wthinoffered one yearlo If.however,the the ower. GAS-EA.SYSTEM-I1NC.40UTLETS 6.00 or improvement is sold within ane year of completion,the owner GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE builder will have the burden of poising that he did not build or im- RES IND CON PB other prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 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-O A.) 1.00 contracts for such projects with a contractortsl licensed pursuant to SEWER-SANITARY-STORM EA.ffiJ10.00 the Contractor's License Law. TRACT NO. PARCEL NO. ❑ 1 am exempt under Sec. ,B.&P.C.for this WATER HEATER 6.00 reason Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING eupeftirla 5.00 I hereby affirm that Phave a certificate of consent to self-insure, ZONING ENG.SITE NO. or a certificate of Workers'Compensation lnsuraoce,or a certified . copy thereof(Sec.3800,Lab.C.). Policy No. Company 0 ❑ Cenifl,d copy is hereby furnished. FIRE SPRINK ENERGY T-24 Z 2 ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD. OI+ ApplicantY ❑ N❑ Y ❑ No ~ wPERMIT ISSUANCE 10.00 v A. . . jr CE RTI F I CATE 01'17%IoM PT ION FROM WORKERS' - LU > COMPENSATION INSURANCEPLG.CONTR. LID.NO. PLG.' /' 1 O (This section need not be completed if the permit is for one TOTAL /q YPtoo❑ZONE Lu,c ❑ N❑ Y❑ N❑ Z) Z hundred dollars(S100)or less.) U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issu'd, shall not employ any erson in a mann so s to U berm he Worker C ati n sof d yl. U a Dat Applicant ALTER OR ADD TO MECH. 5.00 BUILDING . } so NOTIC i TO APPLICANT: If,a ter making this Ccrtificale of 17s-- F_ 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 10=1 .F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNI =C.F.M.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending akency for EXHAUST HOOD (WITH DUCT). 5.00 �� the performance of the work for which this permit is issued(Sec. HEATING UN 0� .U.) 8.00 MICROFILM 3097,CiN.C.). f Lender's Namc HEATING UNIT IOV ER100,000 B. U.) ELECTRIC 3, Ix � Lender's Address I certify that I have read this application and state that the above VENT]LATION Q N. information is correct. I agree to comply with all city and county PLUMBING 5----`� 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 OZ- above-mentioned properly for inspection purposes.` (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 City in consequence of the PERMIT ISSUANCE 10.00 Q granting Of i3 permit. MECH.CONT. LIC.NO. MECH. A�,�/�. r�s�a7 TOTAL TOTAL p Ov Sigma d�fe of ppllcant/Co Nrat;e r - ale OFFICE COPY -'