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C8556APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENTI FI CATION APPLICATION &PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER ���� ADDILDIN ARESS 0 R PLAN CHECK VALIDATION NAME QJT�Y. ELECTRIC PERMIT FEE N A oRs NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 _ LIGHTING FIXTURES 10.00/1.00 IC. NO. roNT A R ADDRESS PPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 PHONE DATE OF APPLICATION R C OR ENGINEER LIC. No. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ARCH.OR ENG.PERMIT ADDRESS SPECIAL CIRCUIT 5{00 VALIDATION EMP. METER OR POLE INS. 20.00 ZIP APPLICANTS ADDDRESSDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 y LICENSED CONTRACTORS DECLARATION TEMP. POLE ,2 30.00 1 hereby affirm that 1 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 and effect. License Class S Lic. Number 1)atcLL�G� ConlremorE o�W''N''G R -B u1LUBk ULCLn Rn'1'lo firm that I am ex from t hu Con l raw t o r'.s License 1 hereby affim Luw I'.. the following reason. (See. 703 LS, ]rosiness and Professions Code Any city or County which requiresu permit to constrtmt,alter, improve, demolish, or repair any structure, prior to its issuance, also requires tire Glc e applicant for such permit to a signed statement (hat he is licensed pursuant to lire provisions of the Contractor's License ISSUANCE DATE BLDG. ELECT. PLG. MECH. ' BUILDING PERMIT INFORMATION M ISC.'- REFER TO ORD VALUATION �QD $/FT. ' PERMIT ISSUANCE 10.00 �--- ELEC. CONTR. LIC. NO. ELEG ` TOTAL PERMIT TO OTY. PLUMBING PERMIT FEE Law (Chapter 9 (commencing with Section 7000) of Division 3 of tine Business and Professions Code) or that he is exempt therefrom and IaV %CQ/'S 11- QIe STORIES TYPE CONSTR. the basis fm lire alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant Lou Civil penalty of not more than five hundred dollars ($500).1: n ALTER -DRAIN -WATER (EA.) 5.00 ❑ I, as owner of the property, or my employees with wages as (heir Sale compensation, will do the work, and lire structure is not BACK F LOW PROTECT. DEVICE 4.00 OCG GROUP RES. UNITS DRAINS -FLOOR, ROOF, AR EA, COND. 5.00 - intended or offered for sale (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 does such work himself or through his own employees, provided that such improve- mentsarenolintendedoroffered for sale. It, however, the building FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE GAS-EA.SYSTEM-11NC.40UTLETS 6.00 or improv anent is sok! within one year of completion, the owner- builder will have lire burden of proving that h e did not build or inn- prove for purpose ofsale.).INDUSTRIAL ❑ I, as owner of the property, an, exclusively emntrmeling with GAS - EASYSTEM -OVER 4 (EA.) 2.00 . BUILDING USE RES IND CON PB Omer ❑ ❑ ❑ ❑ ❑ . . WASTE INTER3000 licensed contractors to construe( the project 1Sce. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of properly who builds or improves thereon, and who LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. 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. ❑ l am exempt under Sec.-, BAP.C. for this reason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC. DATE ACE. FILE NO. WATER TREATING EQUIP. 5.00 WORK ERS'COMPENSATION DECLARATION I hereby affirm that 1 have a certificate ofcoment to self -insure. or a Certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy thereof (See. 3800, Lab.C.lt, Policy No. Company FIRE SPRINK Y ❑ N❑ ENERGY T-24 Y ❑ N❑ ❑ Certified copy is hereby fumished. ❑ Certified copy is Filed with 0m city inspection division. APPliciunt MISC.- REFER TO ORD. CIiR 1'1 P I CA IT 0 F Ii X BM V PIO N P R M WO R K I'R S' PERMIT ISSUANCE •10.00 FLOOD ZONE A.L.U.C. COMPENSATION INSURANCE This sec(iom,need not be completed if the permit is for one PLG. CONTR. LIC. NO. PLG. TOTAL Y [:] N❑ v ❑ NE] hundred dollars (5:00) or IessJ I cerlily that in the pe,f ormince of the work lin. which this per mit is issued, I shall not employ any person in any manner so as to OTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING - S JOU become subject to the workers' Compensation Law f California. Date --� Applicant d -/,Q� NO'I'I LICANT: If,'9f rr`!hr rob flu arhlie. of Ex- ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 PLAN CHECK emption, you should become subject w the Workers' Compensation provisions of lire Labor Code, you most forthwith Comply with such provisions or (his permit shall be deemed revoked.. FEE AIR HANDLING UNIT (TO 10A00C.F.M.) 4.00 AIR HANDLING UNIT(OVER 10)000C.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency lot EXHAUST HOOD (WITH DUCT) 5.00 the performance of the work for which this permit is issued (Sec. 3097, Civ.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Name Laulor's Address HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC '� L fa I certify that l have read OR., ambertion and slate that the above VENTILATION FAN (SINGLE) 4.00 information is correct. I agrge to comply with all city and county ordinances and state laws relating to building Construction, and PLUMBING - BOILER-COMP13 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL hereby authorize representatives of this City to enter upon the above mentioned property for inspection purposes. MISC. - REFER TO ORD. CONST. TAX (We) agree to save, indemnify and keep ]taintless the City of nd expentts which Cupertino against liabilities, judgments, costs a""" may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 granting of this permit MECH. CONT. LIC, NO. MECH. e � OTA, TOTAL as $t n lure A ncan Contractor al INSPECTOR COPY