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8501 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT O ADDRESS t Ter BUILDING - ELECTRICAL-PLUMBING-MECHANICAL WNE PLAN CHECK VALIDATION NAME QTY. ELECTRIC PERMIT FEE • (( T PHONE 7-4Z 77 NONrrRAcroRs I 21 OUTLETS:SWITCHES-RECEP 10.00/1.00 NAME / LIC.NO. / t LIGHTING FIXTURES 10.00/1.00 CONFERACTORS APPLIANCES-RESIDENTIAL 4.00 ADDRESS ( PHONE / PANELS 10.00 DATE OF APPLICATION RRLHI ECi PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P,C.NO. OR ENGINEER LIC.No SIGNS TRANS. 3.00 ARCH,OR ENG. PERMIT VALIDATION ADDRESS / SPECIALCIRCUIT 5.00 ZIP EMP.METER OR POLE INS. 20.00 APPLI MOTORS SEE FEE SCH. `J ADDRDDRESSSS SERVICE CHANGE 20.00 0 LICENSED CONT'RACTORS DECLARATION TEMP.POLE 30.00 a v v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE b 4 H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. F w z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑ Z o m - License Class -rat Lic.Number e r •( 4 r w Date qGto Contractor ��$6 a x f BUILDING PERMIT OWNIi IiR R-BUILDDECLARATION ¢,o INFORMATION w3 LL 1 hereby affirm that 1 am exempt from the Contractors License MISC.- REFER TO ORD Fuoj Law for the following Rason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION Code:Any city or county which requires a permit to construct,alter, ¢ K¢ 0 improve,demolish,or repairemy structure,prior to its issuance,also ELEC.CONTR. - LIC.NO. ELEC. on o ¢ requires the applicant for such permit to file a signed statement that TOTAL N w ora u- PERMITTO G he is licensed pursuant to the provisions of the Contractor's License rzi Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the a Business and Profcislons Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE N/V'1 f/CGf S rC w 7L7 4 or r p the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. a. by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00 1 of not more than five hundred dollars(S500t): ❑ I,as owner of the properly,or my employees with wages as BACK FLOW I PROTECT. DEVICE 4.00 oce.GROUP RES.UNITS their sale compensation,will do tirework,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 ' property who builds or improves thereon.and who docs such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE himselfor AW hrough ownemployees,for sale.11,ed that however, the inmldinros GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 t nm Ns arv�mc intended or offered for sale.If. mpleveq the building or improvement is sob within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 builder will have the burden of proeing that he did not build or im- BUILDING USE prove for purpose m'sale.). INDUSTRIAL WASTE INTER. 30.00 ES IND CON pe Omer ❑ 1,as owner of the property,ani exclusively contracting with ❑ 0 El ❑ ❑ licensed contactors In construct lire project(See 7044,Business LAWN SPRINKLERSrI-INC 5 V.8. 6.00 ASSESSORS PARC ELNO. and Professions Code:The Contractor's License Law docs not apply ' to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OV ER'5(EA.) 1.00 contracts for such projects with a contraclurls)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. Cl I am exempt under Sec. ,B.&P.C.for this WATER HEATERW/VENT f 6.00 reason Owner 'Dale WATER SYSTEM 5.00 Acc.DATE ACC.FILE NO. WORK Ii RS'COMPI.NSA""PION DECLARATION WATER TREATING_ EQUIP. 5.00 ' I hereby affirm that 1 have a certificate of consent to self-insure. IZONING ENG.SITE N0. or a certificate of Workers'Compensation Insurance,or a certified copy themuf(Sec.3800,Lob.CJ. , Policy No. Connpany-C..1/iiI ew 0 ❑ Certified copy lshcreby furnlsbed. Uhf r tt�1 (�L( .IRP SPRINK ENERGY T-2< Z Z ❑ Certified copy is Tiled with the city ms��p"A o 11i 1"... p Applicant MISC- REFER TO ORD. Y N❑ v NE] T PERMIT ISSUANCE 10.00 LU - CIiR'1'IPICATH OPIATIOIINS FROM WORK IiRS' FLOODZONE A.L.u.c. IL need be co N INSURANCE PLG.CONTR. LIC.N0. PLG. Y E3 NE] Y❑ NF] � Z This section need not be completed if the permit is for one TOTAL hundred dollars(S 100)or ICs.) U 0 1 certify that in the performance of lire work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY LL I- nn it is issued,1 Jr.]].vnot employ any person in any manner so as to O w become subject to the Workers'Compensation Laws of California. Q. Dam Appl"°nt ALTER OR ADD TO MECH. 5.00 BUILDING 615-0>- (0 NO'I'ICF TO APPLICANT: If,after making this Certificate of Ex- Z enquion,you should become subject to the Workers'Compensalion 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 10,000CF.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for I EXHAUST HOOD(WITH DUCT) 5.00 the performance of lire work for which this permit is issued(Sec. MICROFILM 3097,Civ.CA HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC I 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 PLUMBING ordinances and state laws relating tD building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the above mentioned properly for inspection purposes. BOILER-COMP (over 100,000 BTU)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 PERMIT ISSUANCE 1000 CONST.TAX may in any way accrue against said City in consequence OC the . �g of Inds permit. MECH.CONT. LIC.NO. MECH. 1 �� TOTAL TOTAL 1 lar Ap cant/Contractor Date INSPECTOR COPY 1 (