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5478 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY i { ' BUILDING PROJECT lDENTIFICATION APPLICATION & PERMIT v PERMIT NUMBER AooHEss4 �oJ 09ci . 1 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL OWNER'S �V PLAN CHECK VALIDATION A . NAME �� � OTY. ELECTRIC PERMIT FEE 1 PHONE , CONTRACTOR'S NAME L.tN/',l - /T, y ^ UTLETSSWITCHES-RECEP 5.00/1.00 1-M-r L . ZJV r� LIGHTING FIXTURES 5.00/1.00 �h CONTRACORs ! APPLIANCES-RESIDENTIAL 4.00 AOUH E55 . �` ('� Yafx� LO PHONE-/�l�l� PANELS S.00 I' DATE OF APPLICATION ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO. O11 ENGINEER ' LIC.No. / SIGNS TRANS. 3.00 ARCH.OR ENG. i PERMIT VALIDATION ADDRESS IO SPECIAL CIRCUIT , 5.00 ZIP / EMP.METER OR POLE INS. 15.00 ' APPLICANT i+MOTORS SEE FMHADDRESSSERVICE CHANGE o o �j LICENSED CONTRACTORS DECLARATION -021a U u Y -hereby al'Iirnl that I am licensed under provisions Ol Chapter 9 ISSUANCE DATE m< H (connmencing with Section 7000)of Division 3 ofthe Business anti EECTPLGMECH. Nz 1'rolessionsCod• andlicense is in full fon ❑ ❑ ❑O m - License Cl s Lic.Number I�.!o Date - - Contractor J OFGf4I , _ BUILDINGPERMIT ¢ w a OWNii R-B UILDIiR UECLARA PION INFORMATION " MISC.- REFER w 3 u w I hereby affirm,that I am exempt from the Contractoh License VALLATION 8/FT. Oj Law for the Hollowing reason.(Sec.7031.5,Busines,zmd Poifssions PERMIT ISSUANCE - mom Code:Anycity orcounty which requires a permit to construct,alter, M2 Qimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. - DLL requites the applicant for such permit tU file a signed statement that 4f vIM a ���.r{�� TOTAL PERMIT TO n w m be is licensed pursuant to the provisions of the Contractor's License C,ILII p r Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe (A1':Krit C1-dFK+ Q Nosiness and Professions Code)Or that he is exempt ihcrcfrom and QTY. PLUMBING PERMIT FEE 1 M the basis for the alleged exemption.Any violation of Sectioa7031.5 STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 of not more than live hundred dollars 05001.1'. ❑ I,as owner OF tire property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS �- their sole compensation,will do the work,and tire structure Is not intended or offered for Sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 Code:'file Contractor's License Law does not apply to an owner of proocrly who builds or improves Finned,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE • himself or through his own employees.provided that such improve- mentsarcnot intended oroll'cued forsale.ll,however,lire building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4,00 or improvement Is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA ) 100 BUILDING USE builder will have the burden of proving that he did not build or int- . . . RES IND CON PB 1 Omer prove for purpose Of Vdc.). INDUSTRIAL WASTE INTER. 20.00 ❑ I,as owner of lire moperlY,am cxclusivcly contracting with ❑' [1 ©" ❑ ❑ licensed contractors t0 construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. and Professions Code The Contractor's License I.aw does not apply to art owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a contramuts)licensed pursuant to lire Contruc n',License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO. ❑ tum cxcnhpt under sec. ,B.&ItC.Inr this WATER HEATER W/VENT 4.00 rea,un Owner Date WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO. WORK FRS'COVIPENSATION DECLARATIONa WATER TREATING EQUIP. 4.00 1 hereby al lion that I hove a certificate of conWelf sent s -inch ZONING m a cerl ifwale ill Workers'Compensation InsT¢ance,or a certified ENG.SITE NO. copy thereof(Sec.3800,Labl:.1..�HNI' CIPL l/l.11 OA) 1' li y No. Company O , rtified copy is hereby Furnished. FIRE SPRINK ENERGY T 24 z ❑ Ce lift4 d alpy -s lilcd�with til• itY inspection Aiv sio . 0 AppticumtKIx)Ir_1Z,4 rl [ifT}E/-1 L. 0 1 '`�- MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑ M T CERTIFICAI'1:OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C. LU 1 C051PENSAIION INSURANCE PLG.CONTE. LIC.NO. PLG, YE]d 0 (This section need not he completed if the permit is for one TOTAL N❑ Y N❑ ❑ Z hundred dollars(S 100)or kis.) U O 1 certify that in the perfomhance of the work for which this per DTV. MECHANICAL PERMIT FEE FEE SUMMARY F mit is issued,1 Shull not employ any person in any manner m as to U become subject to the Workeri Compensation Laws of California. nru. Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING m NOTICE TO APPLICANT: if.after making this Certificate of 13x- Z eu,nion,you should becom,subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK provisions of the [,.be, Code, you most I'..thwilll comply with FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 lire performance of the work for which this permit is issued(Sec. MICROFILM 3097.Civ.c.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lender's Name H EATI NG UN IT(OVER 100,000 B.T.U.)7.50 Lender's Address ELECTRIC O I eerily that I have read([us application and slam that(lie above VENTILATION FAN (SINGLE) 3.00 inlorninlion is correct. 1 agree In comply with :ill city and County BOILER-COMP13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING _ ordinances and stat, laws relating to building construction, and hereby authority representatives of this city to viler upon the - above-mentioned property for inspection purposes. BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL (We) agree tat save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costa and expenses which CONST.TAX may in any way aeeru, against said City in consequence OF the PERMIT ISSUANCE 3.00 olid ftlispe mL ECH.CONT. LIG NO. MECH. - 3 217 TOTAL TOTAL Signature ofA plicant/Contractor _ Date INSPECTOR COPY