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C8303 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY \ BU LOI NG PROJECT I DENTI FICATI ON PERMIT NUMBER BUILDING APPLICATION & PERMIT ADDRESS 92 5 G �� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 3 OWNER'S ^ PLAN CHECK VALIDATION NAME U 11 dn-aa QTY. ELECTRIC PERMIT FEE PHONE NOMERAC DRs OUTLETS-SWITCHES-RECEP 10.0011.00 LIC,No, LIGHTING FIXTURES 10.00/1.00 no"T ess Tons gy1)y APPLIANCES-RESIDENTIAL 4.00 ii, S PHONE -��{ PANELS 10.00 DATE OF APPLICATION ARRCHITECT 1 PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO. ENGINEER /` c.-bsec.No. SIGNS TRANS. 3.00 ARCH,ORE G. PERMIT VALIDATION ADDRESS SPECIAL CIRCUIT 5.00 IP EMP. METER OR POLE INS. 20.00 APPLIC s ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 ' [ o o LICENSED CONI RACTORS DECLARATION TEMP.POLE 30.00 ¢is U I hereby affirm that I ani licensed under provisions of Chapter 9 ISSUANCE DATE N Z w (commencing with Section 7000)of Division 3 of the Business and a H BLDG. ELECT. PLG. MECH. H N z Professions Code,and my license is in full force and e((ec. ©` ❑ ❑ ❑. 00,A- Lice use Class - C."o Number O r IJatc Contractor a m fBUILDING PERMIT ¢ ¢ ¢ OWNER-BUILDER DECL ATION ¢ W U INFORMATION w0 LL m I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD ao ¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT. Code:Any city or county which requires a permit to construct,:dler, '1'1 ¢ K Q 0 inpmwe,demolish,or repair tiny structure,prior m its issuance,also ELEC.CONTR. LIC.NO. ELEC. ✓V 00 n w m u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO he is licensed pursuant to the provisions of the Contractor's License r i Law(Chapter 9(commencing with Section 7000)of Division 3 of the io Business and Professions Code)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE /ciU9 At/ /. .Zk40 JI!5 ¢ H o the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR. nam by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars(S500)J: 0 I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCG GROUP RES.UNITS their Sole compensation,will do the work,and the svucture is not intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE ® himself or hot intended own tared for sale.If,ho ever,the improve- GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00 mems are not irrend ld or of Pored for sale.If,however,the building or lm r will have is sob within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 owner- builder will have[he burden of proving that he did not build or im- BULLRING USE prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB other ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Code:"fhe Contractor's Licrow Law does not apply to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a contracto0s)licensed pursuant to the Commctoh License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. re❑nl am exempt under Sea .B.&P.C.Por tllis WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORK ERS'COMPENSA'1'ION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a a rtificme of consem to s,IGinsure, certificate of Workers'Compuuation Insurance,or a certified ZONING ENG.SITE NO. T copy thereof(See.3800,Lab.C.).�NdUS?Ri9 �- / Policy No. Company O ❑ Certified copy is hereby furnished. 7� P FIRE SPRINK ENERGY T 24 Z 2 /q/Certified copy G Bled with the chy nyecTion arvlslbn. 0 1 p cant MISC.- REFER TO ORD. Y❑ No Y ❑ N❑ ~ w PERMIT ISSUANCE 10.00 ft, CIiR FIC COM OPSATIOTINS (BOMWORKERS' FLOOD ZONE A.L.U.C. W > COMPENSATION INSURANCE PLG.CONTR. LIQ NO. PLG. (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑ hmWord dollars(S 100)or Tess.) U O 1 tariffs that in the perWrmancr of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY Ek I- , mit is loand,I shall not employ any person in any tanner so as Io O w become subject to the Workers'Contpe cation Laws of California a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING >_ m NO'h10E'f0 APPLICANT It,alter making this Certificate of fix- - F Z empfion,you should become subject to tine 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=C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE � oo 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.). H EATI N G U N IT ITO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC Icertif'y that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 inllvnmtirn is correct, I agree to comply with all city and county PLUMBING ordinances and state laws relating to 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 property for inspection purposes. BOILER-COMP(Over 100,000 BTU(SEE FEE SCH. MECH ANICA L'\ (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 10.00 CONST.TAX may in any way accrue against Said City in consequence of the -] grami Of this permit / / / MECH.CONT. LIC.NO. MECH. � (4( ;Al, ! l)l � OTAL TOTAL4d�� 00 Sng•{lihue o App n ant on a or Date INSPECTOR COPY