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5804 4�1 1y` APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY \ BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER )01 aWLDMG // APPLICATION & PERMIT AOORESS �65"' ©MR V �/ .-. � �A PFYI )?r BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 580.4 OWNER'S _ - PLANCHECKVALIDATION - NAME a`53" QTY. ELECTRIC PERMIT FEE MR -t- 83161 NAME cTORs UTLETS-SWITCHES-RECEP 5.00/1.00 ADMNAME LIGHTING FIXTURES 5.00/1.00 CONItHACTO s PPLIANCES-RESIDENTIAL 4.00 ADDRESS ,} NOVO 3 O�DEV/ Ct P..N PANELS5.00 DATE OF APPLICATION ARCHITCCT SIGNS 6.00 PLAN CHECK FEE OR ENGINEER , I - LIC.No. SIGNS TRANS.- 3.00 .ARCH.OR ENG. - SPECIAL CIRCUIT S.DO PERMIT VALIDATION ADDRESS ZIP EMP.METER OR POLE INS. 15-00 ' APPLICANTS _ MOTORS SEE FEE SCH. ADDRESS SERVICE CHANGE = 10.00 p/MFIO w o O LICENSED CONTRACTORS DECLARATION S -( 'O 1 u u I hereby affrrn that I am licensed under provisions of Chapter 9 ISSUANCE DATE w 3 m (commencing with Section 7000)of Division 3.f the Business and _ BLOG. ELECT. PLG. MECH. F H z_ Professims Codc d m liccnu is in full fore' d of eVL z o,A - icensc C'ss Lic.Number • ^ .. ❑ '❑ ❑ ° it,z �_ ° Date Contractor Contractor $! BUILDING PERMIT Q y E J ¢ ¢w4 OWNER-BUILDER DECLARATION - INFORMATION wLL r `1 hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD u04 Law for lire following reason. 7031.5,Businessand Pr.fcssions PERMIT ISSUANCE VALUATION $,/FT. _ 6.00 O Code:Any my or county which reywres a permit to construct ulleq aQQO improve,demolish,.or repair any structure,prior to its issuance.also ELEC_CONTR. LIC.NO. ELEC. 0 ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMITTO u w m u he is licensed pursuant to the provisions of the Contractor's License F z¢ Law(Chapter 9(commencingwith Section 7000)of Division 3 of the "Business and Professions Codc)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEQ ¢ I-a the basis for the alleged exemption.Any violation of Section 7031.5 STORIES Es TYPE CONSTR. a3 _ b5.any applicant for a permit subjects the applicant Ina civil penalty ALTER-DRAIN&VENT-WATER IEA.14.00 //L 9u J kL llecar of not more than five hundred dollars($500)Ji ❑ I,as owner of the property,or my employees with wages as BACK F LOWPROTECT.DEVICE 2.00 OCC. ROUP RES.UNITS their sole emn..cmation,will do the work,and the structure is not intended or offered for sale(Sec. 7044,.Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 ur- 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 TOTALACREAGE himself or through his own employees,provided that such improve- mentsare not intended oroffered for sale.It however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00 orimprovement is sold within one year of completion,the owner- -GAS EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE builder will have the harden of proving that Ise did not build.r int' - RESIND CON PB Other Prove r,r,orpw a,,u,,).. INDUSTRIAL WASTE INTER. - 20.00 ❑ I,as owner.r me property,an exmnafvely a.ntracting with ❑ ❑_ [:j ❑ CD license) contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. and Professions Code:The Contractors License Law does not apply to an owner of property who builds or.impruvcs thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a contractors)licensed pursuant to the Contractor's License Law. SEWER-SAATAR W/VENM EA.200ft/4.00 TRACT NO. PARCEL NO. ❑ I;un exempt rade,See. ,R.&P.C.Rn this WATER HEATER W/VENT,. 4.00 [Cas011 Owner ' Date WATER SYSTEM 4.00 ACC.DATE ACC,FILE NO. WORK ERS'CONIPENSATION DECLARATION WATER TREATING EQUIP. 4.00 ' 1 horeby fFn.that I hare a certificate of consent to self-insure ZONING _ or a certificate of Worker:Compensation Insurance,or a cc,t I ed ENG.SITE NO. copy then..�{Sec 809.Lab.C.1. ,1 PollCy N.SdF/7Y Xivmpany SL4/�ciN� 0' ❑� ��'' rlified copy is hcrchy furnished - - FIRE SPRINK ENERGY T-24 .z 2 A'Certifv d.fie"wu copy is;fled witk. c.city inspect.... division. O Applicant, MISC.- REFER TO ORD: Y ❑ No v ❑ N❑ I cc LO CFROFICATEOP E%I!MMION�FROM WORKERS' PERMIT ISSUANCE - 6.00 FLOODZONE IU > COMPENSADON.INSURANCE PLG.CONTR. LIC.NO. PLG. CL Q (This section need not be C.euticted if file permit is for.tic TOTAL Y❑ N❑ Y❑ ry❑ :D Z hundred drillers(S 1001 or Ius.S' ' U O • I entity that in the performance of the work for which this per- QTY - MECHANICAL PERMIT FEE FEE SUMMARY Li I- mit is issued.I shall nut employ any person in any manner so as to U beeon.e subject to tire rk e Woer: nsa Competion Laws of California. BUILDING W Date Applicant - } ran NOTICE 10 APPLICANT: If,atter making this Certificate of Ex ALTER OR ADD TO MECH. 4.00 F Z cmpfion,you slumld become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK provisions of the Labor Code,.you must forthwith comply with 'FEE, such provisions or this permit shall be dec tied revoked. AIR HANDLING UNIT(TO 10JJOOC.F.M.) 3.00 CONSTRUCTION LEN DING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE CS7i 1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 the performance of the work for which this permit is issued(Seca MICROFILM 3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.17.50 ELECTRIC'' 1 Lender's Address I certify that I have read this application and state chat the above VENTILATION FAN (SINGLE) 3.00 �• information is'correct. I agree to comply with all city and county nlLER-COMPl3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING redinances'and state laws relating to building "n ruction,and hereby authorMe.representatives of this city I.-caler up.n the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned properly for inspection purposes. - (We) agree to save, indemnify and keep harmless the City or 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 fits PERMIT ISSUANCE 3.00 gmnlingrdtSphiisspermit. MECH.CONT. LIC.NO. MECH: a Lr 7� [ r TOTAL TOTAL 4 Si .rc of A .:cant Contractor to OFFICE COPY