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7275 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY p3#- BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBERBUILDING APPLICATION & PERMIT ADDRESS ' Q O O c� ,14J C � BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 72.75 OWNER'S v ' PLAN CHECK VALIDATION • /6 e " E `�Cr ,tZ,t�� QTY. ELECTRIC PERMIT FEE � vHON pQ CONTRACT NAE ?�ZQJ OUTLETS-SWITCHES-RECEP 5.00/1.00 Crus LIGHTING FIXTURES 5.00/1.00 N . rRAnmPs � Z � APPLIANCES-RESIDENTIAL 4.00 Aooy Ess (/ I,1 G(ir) T4 AQSarc 30 902 p PANELS 5.00 DATE OF APPLICATION ` ARCHITECT Of, ISIGNS 8,00 PLAN CHECK FEE P.C.NO. ENGINEER LIC.NO. SIGNS TRANS. 3.00 ADDRESS ENG SPECIAL SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 15.00 APPLICANTSMOTORS SEE FEE SCH. ADDRESS asiF SERVICE CHANGE 10.00 / woo LICENSED CONTRACTORS DECLARATION < u U I hereby affirm that I am licensed older provisions of Chapter 9 ( ISSU E ATE N a w (imoopmcing with Section 7000)of Division 3 of the Business and 80. 1ELE MECH. H m z Professions Code.and my license a in full force and effect ❑ ❑ z 0 w- License Class Lie.Number- 0 umber 0 m Date Contractor a y E i BUILDING PERMIT ¢ ¢ w u OWNER-BUILDECLA R DERAT[ON INFORMATION F ; n r I berehy attinn Ihafl am exempt from the Contractor's I.ieumse MISC.- REFER TO ORD FLLoj Law lbrthe following reason. 7031.5,Businessund Profc"o., PERMIT ISSUANCE 6.00 VALUATION $/FT. Code:Any city ors'nunty whichrequiresapennil In cnnslnmt.idler. Q�yO /yyy rt ¢ < o improve,demolish,or repair any structure,prior 10 its issuance,also ELEC.CONTR. LIC.NO. ELEC. 4 - ¢ ..•....area the applicant loss such permit to file a signed sralemenl Ihut TOTAL 1 PEY5 TO a w m heis licensed pursuant to the provisions of the Contractor's License ��yy Fzi Law(Chapter 9(commencing with Section 7000)of Division 3 of the /1 a Business and I'rofessions Code)or that he is exempt <'therefrom and QTY. PLUMBING PERMIT FEE VV ¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 sTORICs TYPE CONSTR. d3 �2 by any applicant for a permit subjects the applicant Ica civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 11 of not more than five hundred dollars(S500).): ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS sole compensation,will do the work,and the structure is not amended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 Code:The Contractor i License Law does not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 FJ1 FT FLOOR AREA TOTAL ACREAGE himself or through his own employees.provided that such Impose. morns are not intended Or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00 or improvement is sold within one year of complelion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE buime{{will have the burden of proving that he did not build or all- RES IND CO PB Omer pr fOr purpose of sale). INDUSTRIAL WASTE INTER: 20.00 1,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. 5.00 A55ISSU76 PARCEL NO. :a and Professions Code:'! e COntrnclor•x License Law docs not apply R)rot owner of Pnip• who olds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contmcls for such p ds w) u contractods)licensed pursuant to the asmmemaC se L'(. SEWER-SANITARY-STORM EA,200ft/8.00 TRACT NO. PARCEL NO. . ❑ I:un cscm undo c. ,BARC.for this WATER HEATER W/VENT. 4.00 reason OW1p1 I>at' WATER SYSTEM 4.00 ACC.DATE ACG FILE NO. �f)B K IWI/1TQfPL ION DECLARATION WATER TREATING EQUIP. 4.00 I hereby affirm that I have a certificate of consent m self-insure, or a cenifeme of workers'Compensation Insurance,or a certificJ ) ZOrvhrvG ENG.SITE NO. py Ihcof(Sce.3800,Lab.C.L J `(x/' romPolicy No. Co lipany O/ ❑ CerliNcd copy is hereby furnished. 1 FIRE SPRINK ENERGY L24 Z Z itivCe 'tied copy is fled with the city inspersion division. MISC.- REFER TO ORD. Q Applicant Y ❑ N❑ V ❑ N❑ I- rn PERMIT ISSUANCE _ .00 FLOOOZONE A.L.U.C. Cr - f: !I I'IGCO WI OP EXEMPTION PROM WORKERS' W C(JMPIiNSATION INSURANCE vLG.CONTR. LIC.No. PLG. 1 7 Y❑ N❑ Y ❑ NE]O (this section need not be completed if the permit is lin One TOTAL©( Z Innmrcddollam 1$1001 or less.) U O 1 certify that in the perfommnc;of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL I- niif is issued.I shall not employ any person in any manner so as to U become subject to Ile Wnrkeri Compensation Laws of California. O w Date-AppALTER OR ADD TO MECH. 4.00 licant BUILDING >_ a ED ND'I'ICE 'f O APPLICANT: If,after making this Certificate of Ex- F . Z_ ®option,you should become subject to the Workers'Compensmiun APPLIANCE 4.00 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.NL) 3.00 CONS'I'RUClION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE r I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 the Pelf onnanee of the work for which this permit is issued(Sec. MICROFILM 3097,Civ.C).. HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lenders Names H EATI NG UN IT(OVER 100,000 B.T.U.)T50 Lender's Address- ELECTRIC I certify Ilia(l have read thiel application and state that the abm'c VENTILATION FAN (SINGLE) 3.00 • information is correct. I agree to comply with all city and county - PLUMBING ordinances and stale laws relating to bwl'dingyconstruclion, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 hereby authorise representatives of this city to titer upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL ahova-mentioned properly for inspection Purposes. "•n r-� (Wc) agreeZI y red keep harmless Ihu City of MISC.,- REFER TO ORD. Cupertino ag�jhsents, costs and expenses which PERMIT ISSUANCE- 3.00 CONST.TAX may in an w:ysaid City in consequence of the granting O h pCH.CONT LIG,NO, MECH. 9 ! Za�, TOTAL y TOTAL Sign r of cant/Con or Uate { o S � INSPECTOR COPY