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9483 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER RDILDING APPLICATION & PERMIT ADDRESS 9 n 83 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL Lr OwNER'S PLAN CHECK VALIDATION Nam _ QTY. ELECTRIC PERMIT FEE \ PHONE NgN>ERAcrons OUTLETS-SWITCHES-RECEP 10.0011.00 rvo. LIGHTING FIXTURES 10.00/1.00 aoDRE o s APPLIANCES-RESIDENTIAL 4.00 /�-,� r PHONE PANELS 10.00 DATE OF APPLICATION ORRCHIiECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO. ENGINEER uc.NO. SIGNS TRANS. 3.00 t ADD ESS en.. SPECIALCIRCUIT 5,00 PERMIT VALIDATION ZIP EMP.METER OR POLE INS. 20.00 PANG noxa ssTs MOTORS' SEE FEE SCH. SERVICE CHANGE 20.00 AUG 15 1985 wo o _ LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ,y < U I hereby affirm that I am licensed under provisions ol'Chupter 9 ��rA�g gypprtino LA a w (commencing with Section 7000)of Division 3 of the Business mrd BLDG. ELECT. PLG. MEC F y z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑ Z,o u, - License Class -T - Lic.Number H w Date�� Contractor_ L Q y f J ¢ ¢ w � OWNER-BUILDER DECLARATION - BUILDING PERMIT w ;LL w I hereby affirm that I am excinpt from the Contractor's License MISC.- REFER TO ORD INFORMATION u, u, oa Law for the following reason. 7031.5.B n,inessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT. m � Cade:Any city or county which requires apennit to construct,alter, rtQ Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. O ¢ requires the applicant for such permit to file a signed statement that TOTAL A w m" he is licensed pursuant to the provisions of the Contractor's License PERMITTO 00) z st Busi fess andr9 fc,,i.enCodewith Section is exempt therefrom the F 4 o Business and he alleged exemption, or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢ m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. a3 _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not mor,than five hundred dollar,(S500)J: ❑ 1,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 structure is not intended or offered for Sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AR EA,CON D. 5.00 Code:The Contractor's License Law docs not apply to an owner of property who builds or Improves thercou,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE • himself or through his own employees,provided that such improve nsents are not intended or offered for sale.ll'.however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 huilder will have the burden of proving that he did not build or inr- BUILDING USE prove for purpose of axle, IND CON PR Orher ❑ I,as owner of the roper( INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ E] property,R am exclusively contracting with licensed contractors (.,construct the projecL(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Code:The Contractor's License Law docs not apply to an owner of property who builds or improves thereon,anti wlm LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a contracloRs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 the Contractor's License Law. TRACT NO. PARCEL NO. ❑ l am exempt under Sec. ,B.&P.C.for this reason WATER HEATER W/VENT 6.00 Owner _ Date WATER SYSTEM 5.00 Ace.OATE ACG FILE NO. WORKERS'COMPf NSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent to self-insane. it a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO. copy Otereof(See 3900,Lab.C.). Policy No.l��. n� Company-nl1�+ )G ❑ Cetl N is hereby furn�h i. FIRESPRINK ENERGY T-24 Z Z ❑ Certified//s�cop is filed ith t my nsPection division. FO Applicam ll �� MISC.- REFER TO ORD, YF] N❑ Y [:] NE] CC CERTIF1CATT6OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 c. L COhIPF.NSAT'ION INSURANCE PLG.CONTR. LIC.NO. PLG. d (This section need not he completed if the permit is for une TOTAL Y E] NE] Y [] N� i0 2 hundred dollars IS 100)or less.) U O 1 cerl0'y that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL I- mit is issued, I shall not employ any perwn in any manner w as to become subject to the Workers'Compensation Laws of California. a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } W NOTICE TO APPLICANT: If,after making this Certificate of Ex- F 2 emPtion,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK provisioni,.f the Labor Code, you must forthwith comply wilh FEE U xuch,pr4sionx or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 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(Sec. MICROFILM 3097.Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 ordinancis n correct, I agree to comply with all city and county BOILER-COMP(3 H.P,or 100,000 B.T.U.) 6.00 PLUMBING ordinances and state laws relating m building construction, and hereby authorize representatives of this city es enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. above-mentioned property for inspection purposes MECHANICAL (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.001CONST.TAX may in any way accrue against said City in consequence of the g`agnh�flhlSDF�I(thh)I ��//� /�� MECH.CONT. LIG NO. MECH. TOTAL \/ /' �x'p. lt+l� TOT$,L / nalurc�l A hL 1nl' o t r I7ute + INSPECTOR COPY I