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8454 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER BUILDING APPLICATION & PERMIT 8454 ADDRESS 7 2 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL OWNER'S PLAN CHECK VALIDATION NAME - OTY. ELECTRIC PERMIT FEE NAMERacroms OUTLETS-SWITCHES-RECEP 10.00/1.00 `tJA/ LIC.No. LIGHTING FIXTURES 10.00/1.00 CONTRADDREAS ACrors PPLIANCES-RESIDENTIAL 4.00 CONTR 11)A) p r- PHONE PANELS 10.00 DATE OF APPLICATION ARRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. ENGINEER 4u, No. SIGNS TRANS. 3.00 ARC ass Erva SPECIAL CIRCUIT 5.00 PERMIT ALIDATION zlv EMP. METER OR POLE INS. 20.00 APPLICANTS MOTORS SEE FEE SCH. ARCO ESE ,,1 4 4 /v +v .-.l T 5,u. Dc- r SERVICE CHANGE 20.00 ,00 LICENSED CONTRACTORS DECLARATIONS/v r TEMP.POLE -U�Q-QO "70 Qt Lti 1 hereby affirm that I am licensed under provisions of Chapter 9 IS ANCE AT Ps a N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELE T. PLG. MECH. r m z Professions Code,and my license is in full fume and effect. I❑ ❑ E3 ❑ E, 0 m- License Class Lie.Number 9 m w DateContmclor a x o' a OWNER-BUILDER DECLARATION BUILD)ING PERMIT a o a O INF RMATION X g LL N I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD u O j Law for the following reason(Sec.7031.5.Business and Professions VALUa ON $/FT. H - PERMIT ISSUANCE / 00 Code:Any city or county it ichany structure. requires ore permit to construct,altar, Ir ¢ co improve,he applicant or repair any structure.prior n its issuance,also ELEC.CONTR. LIC.N0. TOTAL O u requires the applicant for such permit to lite a signed statement that TOTAL a w m m he is licensed pursuant to the provisions of the Cdntiaclor s License PERMI H z > Law(Chapter 9(commencing with Section 7000)of Division 3 of the n a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE f i o H o the basis(or the alleged exemption.Any violation of Section 7031.5 STORIE P 00 BTR. n _ by any applicant for a permit subjects the applicant too civil penalty of not more than five hundred dollars(5500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00 ❑ I,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 (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's License Law does not apply to an owner of properly who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- mentsarenotintendedorofferedforsale.IL however.the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 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 that he did not build or ice- BUILDING USE prove for purpose ofsale.). IND CON PB Other e.). INDUSTRIAL WASTE INTER. 30.00 El E] ❑ El ❑ I,as owner of the property,am exclusively contracting with RES licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSE SSORS 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 for such projects with a contractor(s)licensed pursuant to SEWER-SAN V-STORM EA.2001[110.00 the Contractor's License Law. TRACT NO. PARCEL NO. ❑ lamexemptunder Sec. ,B.&NCformis WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent to sell insure or a certificate of Workers'Compensation Insurance,or a certified ;J ZONING ENG.SITE NO. copy thereof(Sec.3800,Lab C.). Policy No. Company 0 ❑ Certified copy is hereby furnished. �'/ FIRE SPRINK ENERGY T-24 Z Z ❑ Certified copy is filed with the city inspection division. ! MISC.- REFER TO ORD. O Applicant YE] N❑ Y ❑ N❑ y CERTIFICATEOF EXEMPTION FROM WORKERS' f PERMIT ISSUANCE 10.00 FLOOD 20rvE A.L.U.C. W > COMPENSATION INSURANCE: PLG!CONTR. LIC.NO. PLG. ❑ ❑ ❑ ❑ Q (This section need not be completed if the permit is for one / TOTAL Y N Y N Z hundred dollars IS 100)or less.) U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL H mit is issued,I shall not employ any person in any Danner so as to Q wbecome subject to the Workers'Compensation Laws of California. a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING >_ y NOTICE,TO APPLICANT: If,after making this Certificate of Ex- )- Z emptied,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 10MC.F.M.) 4.00 CONSTRUCfIONLENDING AGENCY AIR HANDLING UNIT(OVER 10=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 performance of the work for which this permit is issued fSec MICROFILM 3097.Civ.C.). 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 1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 information is correct. 1 agree to comply with all city and county PLUMBING ordinances and stale laws relating to building construction, and BOILER-COMPO H.P.or 100,000B.T.U.) 6.00 hereby authorize representatives of (his city to enter upon the above-mentioned property for inspection purposes. BOILER-COMP (Over 100,0008TU)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 anyway accrue against said City in consequence of the PERMIT-ISSUANCE 10.00 granting of this permit. MECH.CONT, LIC.NO. .MECH �2P ") `. �// �2 TOTAL TOTAL Sign faf�fA ca nlractor D"e INSPECTOR COPY