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9146 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER � BDILDING APPLICATION & PERMIT 9146� p ADDRESS a _ 4 A&II f,/9A/C BUILDING-ELECTRICAL-PLUMBING-MECHANICAL OWNER'S , PLAN CHECK VALIDATION •� NA� / ANf ©A1 bfF7CF 7a �2 U1(l9 7�0 QTY. ELECTRIC PERMIT FEE /^ PHONEr96 1 CONTRACTORS NAME UTLETS-SWITCHES-RECEP JO.QO/1.00 LIC.No. LIGHTING FIXTURES 1DA0/1.00 <-w CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 .A ADDRESS PHONE PANELS 10.00 DATE OF APPLICATION ogcHDEDT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. ENGINEER LIC.NO. SIGNS TRANS. 3.00 ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION ZIP TEMP. METER OR POLE INS. 20.00 APPLICANT'S MOTORS SEE FEE SCH. �J G ADDRESS SERVICE CHANGE 20.00 EL l 02 LICENSED CON'1'RAC'PORS DECLARATION TEMP.POLE 30.00La I C/o Q o u I hereby affirm Unit 1:ml hear..cd under provisions of Chapter 9 ISSUANCE DATE y "' (commencing with Section 7000)of Division 3 of the Business and G y BLDG. ELECT. PLG. MECH. F w z Professions Code,and my license is in full force and effect ❑ ❑ ❑ o i y o License Class Lia.Number aa Dale Contractor a m s " BUILDING PERMIT ¢ ¢ a OWNER-BUILDER DECLARATION ow " 1 REFER TO ORD INFORMATION w3 rF N I hereby affirm that I am exempt from Om Contractor's License MISC.- u O j Law for the following reason.(Sae.7031.5,Businessand Professions VALUATION $/FT. - PERMIT ISSUANCE �D.00 W Code:Any city or county which requires a permit 1.construct,alUer � ¢ ¢ Q p improve,denmlish,or repair any structure,prior la its TOTAL issuance.also ELEC.CONTR. LIC.NO. (j J' n. m u requires the applicant for such permit to file a signed statement that TOTAL / E MIT TO A w he is licensed pursuant to the provisions of the Contractor's License F z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe if 7;4A I ¢ o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE ¢ r- m the basis for the alleged exemption.Any violation of Section 703 L5 STO I TYPE CONSTR. ate _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00 of not marc than five hundred dollars($5001): ❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 their sole compensation,will do the work,and One structure is not OCC.GROUP RES.UNITS intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's License Law does not apply loan owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP ,5.Q0 GY SO.FT.FLOOR AREA TOTAL ACREAGE • himself or through his own employees,provided that such improve- cents are not intended or offered for sale.If.however the building GAS-EA.SYSTEM-11NC.40UTLETS J or improvement is sold within one year of completion,ilia owner- GAS EASYSTEM OVER 4 (EA) 200 builder will have the burden of proving that he did not build or int - . - . . - BUILDING USE Prove to,purpose ofsaln.). INDUSTRIAL WASTE INTER. 30.00 r RE IND CON FB Omer 1,as owner o1 the property,am exclusively contracting with ❑ ❑ ❑ 11 li nsdd contractors to construct that project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 qss ESSORS PARCEL NO. and Professions Code:Tim Contractor's License Law does not apply to an owner of property who builds or improves thereon.and who LAWN SPR IN KLERS-OVER 5 IEA,) 1.00 contracts for such projcets with ncontmct.0,i)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00 the Contractors License Law. A N0. P RCEL . ❑ I ant exempt under Sec.-,B&PC.for this WATER HEATER W/VENT 6.00 reason Owner 71A, Date WATER SYSTEM 5.00x ACC.DATE ACC.FILE NO. WORKERS'(7N1P1iNSA'fION DECLARA NON WATER TREATING EQUIP. 5.00 1 hereby affirm thatsi have it certificate ofconsent to salGinsure, Or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO. ' copy thereof(See.3800,I.A.C.). Policy No. Company - O ❑ Certified copy is hereby lumithed RE BPRINK ENERGY T-24Z Z ❑ Certified copy is Bled with the city inspection division. MISC.- REFER TO ORD. O Applicant Y ❑ NEJ YE] NE n y 5 CERTIFICATE 01'FXEMP'I'ION FROM-WORKERS' PERMIT ISSUANCE �.,.; e10.00 r� FLOODZONE A.L.U.C. CL 0 , COSIPIiNSATTON INSURANCE- PLG.CONTR. LIC.NO. PLG. V N V N CL O ('I'It is sect tun need not be completed if the permit is for one TOTAL (/`•..�_ Z hundred dollar,IS I00)or less.) - C..) O I certify that in the performance of tlm work for which this per- DTV. MECHANICAL PERMIT 'FEE FEE SUMMARY LL H. mit is issued,I shall not employ any person in any manner so as to O L) become subject to the Workers'Compensation Laws of California. Date Applicant BUILDING D >_ vat NOTICE TO APPLICANT': If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 F Z 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 F.M.) 4.00 CONS'ERUCI'ION'LENDING AGENCY AIR HANDLING UNITIOVER IO,0MCFM.16.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 ._ the performance of ilia work for which this permit is issued(Sec. MICROFILM 3097,Ch.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's NamAddress HEATING UNIT(OVER 100,000 B.T.U.)Lender's ess ELECTRIC (/U I certify that I have read this appl'cation and state that the above VENTILATION FAN (SINGLE) 4.00 • information is correct. 1 agree to comply with all city and county PLUMBING (h7 ordinances and state laws relating to building construction. and BOILER-001 H.P.or 100,000 B.T.U.) 6.00 0 _ hereby autioned representatives of this city m enter upon theabove- BOILER-COMP (Ova,100,000 BTU)SEE FEE SCH. MECHANICAL hereby eultior d properly for inspection purposes.to. (We) agree to save, nocinnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino 'against INb1Ir11et,Jfigments, casts wtd expenses which PERMIT ISSUANCE 10.00 CONST.TAX' may in any wry ac ue against said City in consequence of the grain,"' rs Per i. ECH.CONT. LIC:NO. MECH. TOTAL TOTAL ytb' Sign is p o t act r Da he INSPECTOR COPY