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8780 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT �� ADDRESS' UILDING - ELECTRICAL-PLUMBING-MECHANICAL d ANER'$ PLAN CHECK VALIDATION NAME T ELECTRIC PERMIT FEE I'M v orvE NOMECNTRA UTLETS-SWITCHES-RECEP 10.00/1.00 fLIGHTING FIXTURES 70.00/1.00 fO PLIANCES-RESIDENTIAL 4.00 ADDRESS QTry%P NE NELS 10.00 DATE OF APPLICATION ORRCMI ECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE ENGINEER ' LIC.No. SIGNS TRANS. 3.00 ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION ZIP FrEMP.METER OR POLE INS. 20.00 W APPLICANTSMOTORS SEE FEE SCH. ADDDDRESSESS SERVICE CHANGE 20.00 w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ¢ u - I hereby utfirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE ¢ -) H st a (commencing with Section 7000)of Division 3 of the Business 1 h r m i Professions Code,and my license is in full force and a feet. BLDG. ELECT. I PLG. MECH. License Class Lie.Number - F m F w Date�- -Q-Contractor a BUILDING PERMIT Ic 0 w 0 (y WW uF.R DECLARA 1 INFORMATION .w 3 LL H I hereby affirm ilia, I am exempt from the Contractor's License MISC.- REFER TO ORD tsF u. 0 J Law for the following reason.(See.703 1.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT. w 0 Code:Any city or county which Riltd aaa permit to construct,alter, kIF Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. A wiLN LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO $ he is licensed pursuant to the provisions of the Contractor's License Hzi Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe Q Business and Professions Code)or tharh,is exempt therefrom and OTV. PLUMBING PERMIT FEE O(!� • ¢ Oo the basis for tiro alleged exemption.Any violation o(Section 7031.5 STORIES TYPE CONSTR. Ate - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dothis(3500).): ❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC.GROUP RES.UNITS their sole compensation,will do the work,and the st rectum is not intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 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 5.00 SO,FT FLOOR AREA TOTALACREAGE himself or through his own employees,provided that such improve- mints are not intended oroffered for sale.if,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 builder will have the burden of proving(hut he did no . t build or im- BUILDING USE prour prove for impose ofsalc.l. v INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB ' Oche, ❑ 1,as owner of the property,um exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors to construct tiro project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Code The Contractor's License Law rimes not apply to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 contracts for such projects with a contracmr(g licensed pursuant m the Contactors License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ lam exempt under Sec. ,B.&P.C.fur this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. !. WORKERS'COM PENSA'I[ON DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent m sell-insure. ZONING ENG.SITE NO. or a cer ¢xte of Workers•Co penwtio Ins ranee. r a cer,ifie copy if • e -3 Pol �ry 0 r fit c , ere y visho.. I FIRESPRINK ENERGY T$4 Z Z ❑ Cenific a,py is filed with tl uI y inspection division. p APplicam MISC.- REFER TO ORD, y ❑ N❑ v ❑ N❑ Cr N Cfi RI11' :ATI?OFEX:bIPT10N YROMWORKI!RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. W > COMPENSAI'ION INSURANCE PLG.CONTR. LIC.NO. PLG, CL 0 (This section need not be completed if lite permit is for one TOTAL Y❑ N❑ Y ElElN hundred dollars($100)or It.I U O 1 certify that in the performance of Bre work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F- mit is issued,I shall not employ any person in any(Dinner so as to Ow become subject to the Workers'Compensation Laws of California. ED Applicant BUILDING 0. >_ to NOTICE'I'O APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. $,00 F 2 emption,you should become subject to the Workers'Compensation 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 10=C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.EM.16.00 SEISMIC FEE 1 hereby ufTirn that them is a construction lending agcocy for EXHAUST HOOD(WITH DUCT) 5.00 the Pcrfarmance of lire work for which this permit is issued(Sec. MICROFILM 3097,CieC.). H EATI NG UN IT(TO 100,000 B.T.U.) 8.00 Lender's Name ,x Lender's AddreHEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC ss s 1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 information is correct. I agree to comply with all city and county x PLUMBING ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.ot-100,000B.T.U.) 6.00 lie Shereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. BOILER-COMP (GVBr 100,000 RTU(SEE 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 CONST.TAX may in any way ac ue against said City in rsequence of the PERMIT ISSUANCE 10.00 gr ming of this p mi {61/ CH.CONT. LIC.NO. MECH. VV ' TOTAL Ic TOTAL 'I Si re s f h / ntrac or � II INSPECTOR COPY r'