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8445APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING- ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER tS Q, -r V BUILDING aooREss ii i, ���rj/f'/� .a5 » Owry 'S ,�1� �d /- ; NAME /J/�/'VV µ /tr R, PHONE QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION DATE OF APPLICATION NoMrnacrOR's /GNG�/Ss�c� G! Sc. ryo. OUTLETS-SWITCHES-RECEP 10.00/1.00 . LIGHTING FIXTURES 10.00/1.00 ADDRESS ORs 5,1 N.T V PHONE . (, APPLIANCES -RESIDENTIAL 4.00 PANELS 10.00 ARCHITECT OR ENGINEER uc. No. PANELS (OVER 200 AMP) 20.00 C PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ADDRESS ENG. CIRCUIT 5.00 PERMIT PERMIT VALIDATION TEMP. METER OR POLE INS. 20.00 ZIP ADDRESS r'S ADDRESS MOTORS SEE FEE SCH. SERVICECHANGE 20.00 ' LICENSED CON TRACT DECLARATION TEMP. POLE 30.00 I hurehy affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and I'role"imis Cade, uOil my license is in full force and effect License Clan Lic. umber ISSUANCE DATE B%. ELECT. PLG. MECH. EJ )me F actor BUILDING PERMIT INFORMATION OWNER -BUILDER DECLARATION I hereby aNlrm that I am exempt from the Contractor S License Law for the following reason. (Sec. 7031.5, Business and Professions Code: Any city or coumy which requires a permit to construct. alter, MISE.- REFER TO ORD VALUATION �[ / O Q 5/FT. PERMIT ISSUANCE 10.00 ELEC. CONTE. LIC. NO. ELEC. TOTAL improve, demolish, or repair any structure, prior to its issuance. also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License V PERMIT TO QTY. PLUMBING PERMIT FEE Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and STORIES TYPE CONSTR. the basis for file alleged exemption. Any viul, ion of Section 7031.5 by any applicant for a permit subjects the applicant ma civil penalty of nut more than five hundred dollars (SSOO).): i ALTER -DRAIN IS, VENT -WATER (EA.) 5.00 ❑ 1, as owner of the property, or my mnployer, with wages as their sole compensation, will do the work, and the structure is not BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES. UNITS Of DRAINS -FLOOR, ROOF, AREA, COND. 5.00 intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's. License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve - Friends are not intended oroff ered for sale. If, however, the building FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE GAS-EA.SYSTEM-11NC.40UTLETS 6.00 of improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not build or im- prove for purpose ofsaleJ. ❑ I, as owner of lire property, am exclusively contracting with GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 BUILDI RES IND ❑ ❑ G URE PB Omer , ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 licensed contractors to construct the project (Sec. 7044, Business and Professions Cade: The Contractor's I.iccnu Law docs not apply to an owner of property who builds or improves thereon, and who LAWN SPR INKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS -OVER 5 (EA.) 1.00 7 ASSESSOR PARCEL NO. contracts for such projects with a contractor(s) licensed pursuant to Ole Contractors License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. um exempt under Sea ,B.&1'.C. br this .son- WATER HEATER W/VENT 6.00 Owner ., `IS"ate qr WORk 5.'COF-NSATION DIiCLARATIO p WATER SYSTEM 5.00 ACC. DATE ACC. FILE N0. WATER TREATING EQUIP. 5.00 I IICreby ul Drm that 1 have a certificate of consent to self insure. or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy Noeof (Sec.3 Co Lab.C). ���j5 ,�A Policy No. ompany /9 X35 T ❑ Ceri a copy ishereby (Tirrnl5 L [� Certified opY wis led wltlr thhe CilY inspection division. Applicantia G/ FIRE sPRINK Y❑ N❑ ENERGY T24 Y❑ No MISE.- REFER TO ORD. CER'I'IIII•PI�CATTE OF I XEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C. PLG CONTE. LIC. NO. PLG. TOTAL COMPENSATION INSURANCE ('Phis' section need not be complctal if the permit is for one v E] N ❑ Y ❑ N ❑ hundred dollar, (S 100) Or less.) 1 certify that in the performance of fire work for whichthis per- mil is issued, I shall not employ any person in any manner so as to CITY MECHANICAL PERMIT FEE FEE SUMMARY BUILDING ,a"Q become subject to the Workers' Compensation Laws of California. Date ApplicantALTER NOTICI7 TO APPLICANT: If, after making this Certificate of Ex- . . OR ADD TO MECH. 500 APPLIANCE 5.00 PLAN CHECK FEE emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT (TO 10,0001C.F.NL) 4.00 AIR HANDLING UNIT (OVER 10DWC.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY 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. 3097, Cir.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATI NG UN IT (OVER 100,000 B.T.U.)9.50 ELECTRIC Lender'sd Lender's AdAAdress I certify that l have read this ipplieution and state that the above VENTILATION FAN (SINGLE) 4.00 information is correct. I agree to comply with all city and county urdim moss and state laws relating to building construction, and PLUMBING BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL hereby aiuhorize representatives of this city to enter upon the above mentioned property for inspection purpows. MISC. - REFER TO ORD. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments costs and expenres which may in any stay accrue against said City' in consequence of the CONST. TAX PERMIT ISSUANCE 10.00 graN�g f Ibis permit F MECH. CONT. LIC. NO. MECH. TDTAL TOTAL �� F gnalure.1 AptlintilluolrbFuen., D to INSPECTOR COPY