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8776 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT:I DENTI FICATI ON PERMIT NUMBER ADDRESS APPLICATION & PERMIT 8776 ILDING - ELECTRICAL-PLUMBING-MECHANICAL OWNER'$ NAME PLAN CHECK VALIDATION -� ELECTRIC PERMIT FEE PHONE CONTRACTORS AM[RAcro UTLETS-SWITCHES-RECEP 10.00/1.00 rvo. LIGHTING FIXTURES 10.00/1.00 CONTRACTOR ' Aon"ESS APPLIANCES 4.00 `-'DMON PANELS 10.00 DATE OF APPLICATION N ARRCHI ° RE1 41G, • PANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C.NO. ENGINEER LIC.NO. SIGNS TRANS. 3.00 Aooa Ess END. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ' ZIP EMP.METER OR POLE INS. 20.00 AvvucANrs MOTORS SEE FEE SCH. (J ADDRESS SERVICE CHANGE 20.00 o w o LICENSED CONTRACTORS DECLARATION TEMP,POLE 30.00 a u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE y ¢ w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. 0 y z professions Code,and my license is in full force, ul ffce( ❑ ❑ ❑ 0 C m - License Claes Lic.Numhcr o r D Uatc//�--�7l Contractor L a � E l 6 V � � BUILDING PERMIT ¢ w a VV O\ UILDtiR DGCLARAT h 4 D INFORMATION w 0;¢ r I hereby affirm that I am exemMISC.- REFER TO ORD pt from the Conlmctor's License .. o¢ Law for the following reason.(Sec.7031.5.0msinessand Professions VALUATION $/FT. I- - PERMIT ISSUANCE 10.00 �� Code:Anycity or county which Structure, requires une permit prior to is issuance, after ¢ R ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ~ ¢ requires the applicant for Such perinit t0 file a signed statement that TOTAL a w m°' he is licensed pursuant to the provisions of(he Contractor's License PERMIT TO H z aLaw(Chapter 9(commencingwith Section 70001of Division3oflhe �L O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE fY ¢ I- o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. to by any applicant fur a permit subjects the applicant to a civil penalty ALTER-DRAIN IEA.) 5.00 of not more than five hundred dollars($5001): ❑ I,as owner of the property,nr my emplayces with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS their sole compensation,will Jo the work,and the sl ructure Is not intended or offered for sale(See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 C. The Contractor's License Law does nut apply to an owner of properly who builds Or improves lh Creon,and who dOCs such work FIXTURES-PER TRAP 5.00 s0.FT.FLOOR AREA TOTAL ACREAGE • himself or through his own employees,p...vidad flat such improve- merits are riot intended or offered for sale.If,however,Ole building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 or improvement is sold within one year of completion, (he owner- GAS EASYSTEM OVER 4 IEA( 2.00 builder will have the burden of proving that h - . - . e did not build or im- BUILDING USE prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Conor ❑ 1,as owner of the property,am exclusively contracting with licensed contractors m construct the project(Sec.7044,BusinessLAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. \ and Professions Co le:'I he Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts forsuch projectswith a contractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 fire Contractor',License Law. TRACT NO. PARCEL NO. ❑ 1 inn exempt under Sec ,B.&P.C.for()its WATER HEATER W/VENT 6.00 reason Owner Datc WATER SYSTEM 5.00 ACC.GATE ACC.FILE NO, WORK ERS'COMPFNSA'I ION DFCLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent to self-insure, u or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG,SITE N0. I I ab.C.l. 1 1 ' i t of 1 a,`ay All C-i= O L yi he -by fu tS ctt - FIRESPRINK ENERGY T 24 ~ ZO ❑ Corti o cop :Ided with he city inspeT t division. MISC.- REFER TO ORD. ❑ IN Y ❑ N� Apphcan( w CER 'ICA 'OF EKEbIPI'ION FROM WORKERS' PERMIT ISSUANCE 10.00 t Y COD ZONE A.L.U.D. L CO\IPENSATION INS URANCE PLO.CONTR. LIC.NO. PLG. N Y NE]('Phis sec tun need not he completed if lire permit is for one TOTAL 2 hundred dollars IS 100)or lest U 0 I certify (hal in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL U mit is issued.I shall not employ any person in any manner so as m become subject to(he Workers'Compensation Laws of Ca i(orma. GO Dam Applicant r BUILDING } w NO'I'IC6 '1'O APPLICANT: IL after making this CsRifieme of Ex- ALTER OR ADD TO MECH. 5.00 ? enlptiori,you should beconm subject to the Workeri Cumpensatioo APPLIANCE 5.00 PLAN CHECK proons 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 Li'NDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 6.00 SEISMIC FEE I hereby' affirm (hut 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.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 Lender's Address ELECTRIC 1 certify that I have read(his application and slate that the above VENTILATION FAN (SINGLE) 4.00 D© information is correct. I agree to comply with all city and county' PLUMBING ordinances and state laws relating to building construction, and BOILER-ODMP(3 H.P.or 100,000 B.T.U.) 6.00 hereby authorize representatives for ins of this city es enter upon theaboveBOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL hereby autioriz property for inspection purposes.to (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 granting of fI permit. MECH.CONT. LIC.NO. MECH. TOTAL TOTAL $i to Ian/Co ctor I INSPECTOR COPY