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8174 (5) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT �� ADDRESS / ?Tp BUILDING -ELECTRICAL-PLUMBING-MECHANICAL OWNERS PLAN CHECK VALIDATION �DPRA', .�ppp `l�p �'»`67Y. ELECTRIC PERMIT FEE / PHONE .� NAMER° TOR UT LETS-SWITCHES-RECEP 10.00/1.00 LIC.ND. LIGHTING FIXTURES 10.00/1.00 CONTRACTOR ono APPLIANCES-RESIDENTIAL 4.00 / CONTRA PHONE PANELS 10.00 DATE OF APPLICATION AR.CHITECi PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. O ENGINEER uc.No. SIGNS TRANS. 3.00 AAFICH OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 APPLICANTS MOTORS SEE FEE SCH. ADDRESS SERVICE CHANGE 20.00 C o LICENSIiDCONTRACTORS DECLARATION TEMP.POLE 30.00 31ora ¢ v U I hemb,affirm thus I am licensed under provisions of Chapter 9 ISSUANCE DATE nG vNi (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. H w z Professions Code,and my license is in full force and effect ❑ ❑ ❑ ❑ o 0 m W License Class Lie.Number Date Conactor ¢ x trBUILDING PERMIT ¢ ¢ a OWNER-BUILDER DECLARATION ¢ u, v INFORMATION w i LL m 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION S/FT. H LL o a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 Code:Any city or county which requiresa permit to construct,alter, te an Q Improve,demolish,Or repair any structure,prior to Its Issuance,also ELEC.CONTR. LIC.N0, ELEC. ca O LL PERMIT TO ns requires the applicant for Such permit to file a signed statement that TOTAL ' A w m he is licensed pursuant to tire provisions of the Contractor's Licee O Fzi Law(Chapter 9(commencing with Section 7000)of Division 3 of the a Busivess and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE / .1- fEo ^ ¢ H o tire basis for tire alleged exemption.Any violation of Section 7031.5 STORIES n TYPE CONSTR. a3xO by any applicant for a permit subjects the applicant tea civil penalty gLTER-DRAIN -WATER IEA.) 5.00 of not one than five hundred dollars(5500).): - ❑ 1,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 intended or offered for Sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractors License Law does not apply to in owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 Sec FT.FLOOR AREA TOTAL ACREAGE himself re through his own employees. 1,If,however, that such improve. himselfents m But through his owoffered employees,provided that such ein hove"de" GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA ) 200 builder will have the burden of proving that h - . - . . e did not build or im- BUILDING USE prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00 RES IND CON ps Omer . ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.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-OVER 5(EA.) 1.00 contracts forsuch projectswitt a contractorls)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00 • the Contractors License Law. TRACT NO, PARCEL NO. ❑ Iwo exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 reason owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. HW`o'RKhRs'ComPhNS A roN7 I)I iCLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm Unit 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified copy tareof(Sec.3800,Lab.C.). Policy No. Company O ❑ Certified copy is ha eby'I'umishcd. FIRE SPRINK ENERGY T 24 Z Z ❑ Certified copy is filed with lire city inspection division. O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑ ~ wfLRIIHLPERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. ELI 1 COMVrNSAT10N INSURANCE DR61,RS PLG.CONTR. LIC.NO. PLG. , d O (This section neer) net be Completed it the permit is for one TOTAL Y❑ N❑ Y❑ N❑ ZIZ hundred dollars(S 100)or less.) U O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY IL H mit is issued,I shall not employ any person in any manner so as to U become subject to lire Workers'Compensation Laws of California. a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING A a fa } m NOTICE TO APPLICAN"f. If,after making this Certificate of Ex- F2 emption,you should become subject to the Workers'Compenrat ion 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 10MC.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0=C.F.M.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 the 3097 eMICROFILM Civ.C.). of the work for which this permit is issued(See. HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 Lender's Address ELECTRIC I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00 +� information n correct I agree to comply with all city and county PLUMBING informordinaacestion and state laws refuting to building l city uction,and co andmy BOILER-COMP I3 H.P.or 100,000 B.T.U.1 6.00 herchy authorize representatives of this city to enter upon tire above-mentioned property for inspection purposes, BOILER-COMP (Over 100,000 BTU)GEE FEE SCH. MECHANICAL (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. - Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX may in any way accrue against said City in consequence of the grant f th's p mil. o MECH.CONT. LIC.N0. MECH. M2 TOTAL TOTAL /(�,Z lv 'Sig azure ofA phi 'ontract ate r INSPECTOR COPY