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C7208 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT 1 DENTI FI CATION PERMIT NUMBER BUILDING APPLICATION & PERMIT n n^O� aooREss BUILDING W -ELECTRICAL-PLUMBING-MECHANICAL vI L Z2 l Lt/ta]` ON R'S PLAN CHECK VALIDATION "/,"Q)kA/JE',^ G (T�• HONE QTY. ELECTRIC PERMIT FEEP CONTRACTORS OUTLETS-SWITCHES NAME -RECEP 5.00/1.00 �( �((( uc.No./r440 ILIGHTING FIXTURES 5.00/1.00 'AONTRACTO 's S(/ APPLIANCES-RESIDENTIAL 4.00 OOR s �// f ,, S. q/{h Q1 / PHONE 3 -J jI_ PANELS 5.00 DATE OF APPLICATION ARCHITECT SIGNS. 6.00 PLANCHECK FEE 9.C.N0. on NGI E / LIC.No SIGNS TRANS. 3.00 ADDRESS SPECIAL CIRCUIT 5.00 AENG. PERMIT VALIDATION _ oREss .2 � ° O61S nv S/f TEMP.METER OR POLE INS. 15.00 APPLICANT'S s(l�c MOTORS SEE FEE SCH. WFS �' q�,1f� /p a y SERVICE CHANGE 10.00 w�o o LICENSED CONTRACTORS DF.CLARAT'ION ¢-u I hereby affirm that 1 am licensed under provisions of Chapter 9 - ISSUANCE GATE uaHi<n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. H m z I'wfessio la Code,a my license is in full for effect. © ❑ ❑ ❑ z o m- hicenu Class Lic.Number 0 m F w Dale ._,pr..�Contractor ' H - f / "' ' BUILDING PERMIT ¢ ¢ w a i OWNER-BUILDER DECLARATIO INFORMATION w LL r I hereby al']inn that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/FT. r .. o J Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 6.00 Ev'0Code:Any city or county which requires a permit to construct,alter, ELEC.CONTR. LIC. �770Q� ¢ aa 4 o improve,demolish,or repair any structure,prior to its issuance,also ELEC. / y O LL requires the applicant for Such permit to file a signed statement that TOTAL PERMIT TO he is licensed pursuant to the provisions ofthe Contractor's License Hza Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe 4 er Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT .FEE ¢ moo the buil for the alleged exemption.Anyviolation ofSection7031.5 STORIES TYPE CONSTR. ate - by any applicant fora permit subjects the applicant toacivil penalty ALTER-DRAIN& VENT-WATER (EA.) f..00 a•� s/� �� of not mom than five hundred dollars(5500).): ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS their sale compensation,will do the work,and the structure is not intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 -� Code:'I lie Contractor's License Law does not apply to an owner of w property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE • himself m through his own employees,Provided that such improve- / a[ meats o not through or offered employees, or provided that such building GAS-EA.SVSTEM-11NC.40UTLETS 4,00 x0 / or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE -, builder will have the burden of proving that he did not build or int RES IND CON PB Omer pane for purpose of sale.). INDUSTRIAL WASTE INTER. - 20.00 C1 1. ❑ ❑ ❑ ❑ I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(See 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL N0. and P,of,,,ion,Cade,'fhe Con1,actor's License Law does not apply ,a an owner of property wife builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 0 a 6 -' 3a - contracts for such projects with a contractor(s)licensed pursuant to the Contractor's Lwicn.Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO. ❑ I at,,exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00 v- r.om �• Owner Uaa' WATER SYSTEM 4.00 ACC.DATE ACC.FILE N0. WORK ERS'CONP,°WATION DECLARATION WATER TREATING EQUIP. 4.00 I hereby affirm That I have a certificate of consent to sell-insane. TONING \/ or a eetlifieate of Workers'Compensation Insur�at ce,or a artifand ENG.SITE NO. h copy there f 00,Lab.C.). �/ r Lss F}N Policy Nb t pang -ALL r 0 ❑ Cerliticd VnrllF eby furnish FIRESPRINK ENERGY T 24 ❑ Certified s de w' the city inspection division. MISC.- REFER TO ORD. Z O APP]icenl i Y ❑ N❑ Y ❑ N❑ � N( CERT I F]CATE OP EXEMPTION FROM WOR K ERS' PERMIT ISSUANCE6.00 FLOOD ZONE A.L.u.C. LU (7041;NSATION INSURANCE PLO.CONTR. LIC.NO. PLG. d O ('PIn, Section need net be complete,] if the pern it is fur one TOTAL V❑ N❑ V ❑ N❑ Z hundred dollars f$100)or less,) 0 O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY L.L I- mit is issued, I shall not employ any person 1. a manner so as to U bz c slj,ct to the Workcrs'Cnrppy`s' Io L;�is of C4Ilfornin. 0 n Ilutc 7'_L Applicant AnCC L ALTER OR ADD TO MECH. 4:00 BUILDING J } m NO I'I G 7�II O A I'LB.ANT: If,after makMg t its Cerlifl c f fix Z ctiipbon,you should become subject to the WorkersCompensation APPLIANCE 4.00 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)JI00CF.M.) 3.00 CONS7RUCfION LENDING AGENCY AIRHANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE jy I hereby affirm that There is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 thepedimnance of the work for which his permit is issued(Sec. MICROFILM 3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lender's Name P.O� �' -�� T HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC Leader's Address-fs ��_ and - I certify that I have reed this application and state that the aM1ove VENTILATION FAN (SINGLE) 3.00 . • information is correct. I agree m comply with all city and county PLUMBING m onan[cs and ,are laws relating building 4onsvuction, and BOILER-COMP(3 H.P.or 100,0008.T.U.) 4.00 'hereby mtlhorire representatives of This city tD corer on tuphe BOILER-COMP IDw1100,000 BTU)SEE FEE SCH. MECHANICAL shove-n®mioned property for inspection purposes. (We) agree toseve,,inde...ei]'y and keep harmless the City of .REFER TO ORD. Cupertino against liabilities,judgments, costs and u.PcL PS which PERMIT ISSUANCE 3.00 CONST.TAX . may ii any way accrue against lid City in consequence of the granlinh•nit, xmiL MECH.CONT. LIC.NO. . MECH. TOTPL TOTAL SigroaW of Applican/Contractor I le INSPECTOR COPY