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8784APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENTI FICATI ON APPLICATION & PERMIT BUILDING -ELECTRICAL- PLUMBING -MECHANICAL PERMIT NUMBER. 8784 mo-OING ADDRESS 1 OWNER'S PLAN CHECK VALIDATION NAME QTY. ELECTRIC PERMIT FEE vlsorvE NAMERALTOR'S 4/q28,` -QO. R L UTLETS-SWITCHES-RECEP 1QQW1.00 LIGHTING FIXTURES 111D6{4.00 t -d!• moo ess TORS 4) �A PPLIANCES-RESIDENTIAL 4.00 PANELS 10.00 ,�jrq/A PRONE IPANELS DATE OF APPLICATION ARCHITECT OR ENGINEER uc. No. (OVER ZOO AMPI .20.00 PLAN CHECK FEE- P.C. NO. SIGNS TRANS. 3.00 ARCH. oo Ess ENG. SPECIAL CIRCUIT 5.QQ PER MIT VALIDATION TEMP. METER OR POLE INS. 20.00 ZIP APPU CANT'S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 i LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 - I hereby affirm that I am licensed under provisions ol'Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my IlcettSC ",a fall fUreea L'ff `Cl. / License Cla Lie. Number ISSUANCE DATE BLDG. ELECT. ElE] PLG. MECH. ❑ ❑ Dale Contractor BUILDING PERMIT INFORMATION I V - OWNER-BUILDFR DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to construct. alter. improve, demolish, or repair any structure, prior to its issuance, also requires lire appliconl for such permit to file a signed mm, nait that he is licensed pursuant to the provisions of the Contractor's License MISC.- REFER TO ORD PERMIT ISSUANCE to an ` VALUATION $/FT. ELEC. CO TR: LIC. N0. / ELEC. -y S, TOTAL V PERMITTO TY. PLUMBING PERMIT FEE Law (Chapter 9(commencing with See( on 7000) of Division 3 of the Business and Professions Code) or that he isaxempt therefrom and STORIES TYPE CONSTR. lire basis for the alleged esentption. Any violation o(Section 7031.5 by any applicant lir a permit subjects the applicant o a civil penalty W not more than five hundred dollars ($500).): ALTER -DRAIN -WATER (EA.) 5.00 113 I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not BACK F LOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00 intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does riot apply to an owner of property who builds or improves thereon, and who floes such work himself or through his own employees, provided that such improve- ments are not intended or offered for sale. IL however. (lie building FIXTURES - PER TRAP 5.00 50. FT. FLOOR AREA TOTALACREAGE GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 _ or improvement is sold within one year of completion, the owner builder will have the burden of proving that he did not build or im- prove for purpose of sale.). ,❑ 1, as owner of the property, am exclusively contracting with . . . - GAS EASYSTEM -OVER 4 IEA) 200 - \ BUILDING USE RES IND CON PB Omar I❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. licensed contractors to construct tire project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a contractor(s) licensed pursuant to the Contractors License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 -�� TRACT No. PARCEL No. I ❑ lam exempt under Sec.-, B &P.C. for this reason ' WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC.OATE ACC, FILE NO. WATER TREATING EQUIP. 5.00 WORK F.RS'COM PENSATION DECLARATION I hereby affirm (hsl I have a certificate of Consent to self -insure, or a certificate of Workers' Compensation Insurance, or a cerlified ZONING ENG. SITE N0. copy thereof (Sec. 3800, Lab.C.). Policy No. Company FIRE SPRINK y❑ N❑ ENERGY T-14 Y ❑ N❑EXEMPTION by furnished ertded with m ''y ,=,ion division. Ap icant ❑ Co*COMP?FNSATION MISC. - REFER TO ORD. I7RONI WORKERS. PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.II.C. PLG.CONTR. LIC. NO.PLG. TOTAL INSURANCE ('f his section need not be completed if tiro permit is for one YE] N❑ Y❑ NE] hundred dollars IS 100) or less I certify that in the performance of tare work for which this per- mit is issued, I %hall not employ any person in any manner so as to CITY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of Culilbrnia. Dale Applicant NOTICE TO AITLICANT: If, after making this Certificate of Fx- ALTER OR ADD TO MECH.^ 5.00 APPLIANCE 5.00 PLAN CHECK mmption, you should become subject to the Workeri Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be devoted revoked. FEE AIR HANDLING UNIT (TO 10=CF.M.) 4.00 AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LEN DING AGENCY I hereby affirm that there is a consl"relmn lending agency for EXHAUST HOOD (WITH DUCT) 5.00 tire 3097. Civ.).performance of the work for which (his permit is toned (Sea. MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Name Leruler's Address H NNER 9 EATI G UNIT (OV100,000 B.T.U.).50 ELECTRIC (%'U I certify that I hove read this application and state ILI the above VENTILATION FAN (SINGLE) 4.00 information is correct. I agree to comply with all city and county ordinances and slate laws relating to building construction, and PLUMBING BOILER - COMP (3 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL hereby authoriec represenmtives of this city to enter upon the abuse -mentioned properly for inspection purposes. MISC. - REFER TO ORD. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may i y way accrue age' 1 said City in consequ`nce of the CONST. TAX PERMIT ISSUANCE 10.00 So fIIUvPCrmL / MECH. CONT. LIC. NO. MECH. [\ �� TOTAL TOTAL Si a( o Applicant/Con ru r le I INSPECTOR COPY