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8274APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER n 8674 BUILDING ADORES•- e 2.;.��/S� �A .1 A, TJ /i /� OWNERS _ PLAN CHECK VALIDATION NAME, L D� AN PHONE QTY. ELECTRIC PERMIT FEE DATE OF APPLICATION CONTRACTOR'S NAME /`/ pp�J 22 MADI�CX _IC NO. 1 ) �1 OUTLETS-SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 CONTRACTOR ADDRESS PHONE PPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 ARCHITECT OR ENGINEER _ LIc.NO. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. - SIGNS TRANS. 3.00 neo Ess ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION rrEMP. METER OR POLE INS. 20.00 '1 - ZIP _//� nN ,C1Q ry-w/fs O ADPLI DRESS,CANTS ADDRESS /n� lost t ul2vFo I' MOTORS'} SEE FEE SCH. �) SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force �Bfpld effect Limnse Class P-1 Lie. Number i4- ISSUANCE DATE A BLDG. ELECT. ©` PLG. ❑ MECH. ❑ )are Comractori.n� OWNER -BUILDER DECLARATION 1 1 hereby affirm that 1 am exempt from the Contractor's License Professions Law for Athefollowingreason(Sea 70resa permitto Code: Any city or county which requirese permit In construct, aper, or repair any structure, prior n its issuance, also improve, e applicant to fileoft i 9gned Stiltel's Li ense requires thedp pursuant he is licensed 9(co to the provisions of the Conlr:mtsion License he t the provisions Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business Professions Code) or that he is therefrom and BUILDING PERMIT INFORMATION MISC.- REFER TO ORD PERMIT ISSUANCE 1n n0 .� VALUATION 5/FT. �� Q� Q ELEC. CONTR. LIG NO, ELEC. TOTAL +� PERMIT TO STORIES a� QTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. I., tmn Hf basis Iia the allegedexemption. Anyviolation I to action malty by any applicant fore permit subjects the 0). ): mtoacivil penalty by of not more than (ire hundred Dollars ($5001.): ALTER-DRAIN-WATER(EA.)5.00 ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the stcture is not ru BACK FLOW PROTECT. DEVICE 4.00 OCGGROUP HES.UNITS DRAINS -FLOOR, ROOF, AR EA, COND. 5.00 imicnded or offered for sale (Sec. 7044, Business and Prul'cssiom Code: The Contractor's License Law dues not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees. provided that such improve- itemsare not intended oroffered for sale. If. however, the building or improvement is sold within one year of completion, the owner builder will have the burden of proving that he did not build or am- prove for purpose ofsale.).INDUSTRIAL ❑ 1, as owner of Ole property, am exclusively. contracting with F IXTUR ES - PER TRAP 5.00 s0. FT FLOOR AREA TOTAL ACREAGE GAS EA SYSTEM -11NC.4 OUTLETS 6.00 GAS - EA. SYSTEM -OVER 4 IEA.) 2.00 / BUILDING USE RES IND CON PB Omer ❑ ❑ ❑ ❑ ❑ WASTE INTER30.00 licensed contractors rn construct the 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 LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 IEA.) 1.00 ASSESSORS PAHCEL NO. contracts fur such projects with a contract.o') licensed pursuant to the Contractors License Law. SEWER-SANITARYV-STORM EA. 200ft/10.00 (q� fi TRACT NO, PARCEL NO. 1 lam exempt under See ,B.,ivP.G. fur this reason WATER HEATER W/VENT 6.00 'II Owner Date WATER SYSTEM 5.00 ACC.DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 WORKERS'COMPENSAIION DECLARATION I hereby affirm that I have a certificate of consent to seaminsure. Ura Cenifi,ate of Workers Compensation Insurance, or a certified ZONING ENG. SITE N0. copy thereof (Sec. 3800, Leb.CA Policy No. Company !{� o �I o 9 FIRE SPRINK Y ❑ N ❑ ENERGY T.24 I Y ❑ N❑ ❑ Certified copy is hereby furm3hed. ❑ Certified 'opy IY Med with The City mspeclion division. Applicant�Mn.-�rV��/ MISC. - REFER TO ORD. CERTIFICATE OI' EXEMPTION FROM WORKERS' PERMIT ISSUANCE 1. FLOOD ZONE A.L.U.C. PLG.CONTR. LIC. NO. tl - PLG, TOTAL ! COMPENSATION INSURANCE I Putts section need not be completed if the permit is for one V ❑ No Y ❑ IN E] hundred dollars (5100) or less.) I certify that in the performance of the work for which this per- mit is issued, I shall not employ any person in any manner so as Io OTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING . become subject to the Workers'Compensation Laws of California. Dal° Applicant ALTER OR ADD TO MECH. 5,00 NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption, you should become subject to the Workers' Compensation APPLIANCE 5.00 PLAN CHECK provisions M the Labor Code, you must forthwith comply with such provisions or this permit shall be deem ad revoked. FEE AIR HANDLING UNIT (TO 10=C.F.M.) 4.00 AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE 0 J- CONSTRUCTION LENDING AGENCY I hereby affirm that Ilmre is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 the perforniance er rniance of the work for which this perm iv CA it is issued (Sec. MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 6.00 Lender's Nanm loC3.{.tc- Lender's Addres� HEATI NG UNIT (OVER 100,000 B.T.U.W.5D ELECTRIC /� I certify that I have read this application and swte that the above VENT LATION FAN ISINGLE) 4.00 information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and heribyAdve- authorize representatives of This city to toter upon the ubcve-mentioned property for Saes of inspection puityts. PLUMBING (- BOILE--COMP(3 H. P. Or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL v Gni MISC. - REFER TO ORD. CONST. TAX (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue agm t Said City in romsequem<e of the PERMIT ISSUANCE grant this permit. MECH.CONT. LIC. NO. MECH. - TOTAL /U TOTALJ �5^ Signa uregfA lie t/Contract Date I 1 I o INSPECTOR oOPr V fS 9 I