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09621 (2)0 Ir z moo amu Q a H y Z_ O Z H O Q N E x ao Ira' x3 LLLLQ J w x o 0 a k o i lu m N f=a O Z t -- Ix W CL U LL I-- APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY BUI LDI NG PROJECT I DENTI FICATION APPLICATION & PERMIT BUIL- DING ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER O 96211JILDINGADDRESS A 9 AWHER'S NAME CO PHON f ,IQTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION CONTRACTOR'S NAME OUTLETS -SWITCHES -RECEP 10,0011,00 LIGHTING FIXTURES 10.0011,004,660 LIC. NA. CONTRACTOR'SPPLIANCES-RESIDENTIAL ADDRESS 4.00 PANELS 10.00744AHGN1579a- DATE OF APPLICATION OR 3E ENGINEER LIC. No. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P -C, NO. SIGNS TRANS. 3,00 ARCH. AR ENG.SPECIALADDRESS ZIP CIRCUIT 5.00 PERMIT VALIDATION SEP 0 h 1985 City of Cupertino EMP. METER OR POLE INS. 20.00 APPLICANT'S ADDRESS 7.0 MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 1 hereby affirm that I am licensed under provisions of Chapter 9 commencing with Section 7000) of Division 3 of the Business and ProEessians C 1e and y licegse is in full Eorce and effect. License Class%``_¢ Y- bLic. Number Date nhactor O ISSUANCE DATE BLDG. ELECT. PLG. MCH OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the fallowing reason. (Sec. 703 1,5, Business and Professions Code: Any city or county which requires a permit to construct, alter, 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 Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exemp I. therefrom and BUILDING PERMIT INFORMATION MISC. - REFER TO ORD VALUATION SIFT. PERMIT ISSUANCE 10.00 ELEC. CONTR. LIC. NO. ELEC. TOTAL PERMIT TO QTY. PLUMBING PERMIT FEE STORIES TYP& CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than Five hundred dollars (5500).): ALTER -DRAIN &VENT -WATER (EA.} 5.00 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not BACK FLOW PROTECT. DEVICE 4,00 OCC.GROUP RES, UNITS DRAINS -FLOOR, ROOF, AREA,COND. 5.00intendedorofferedforsale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner or property who builds or improves thereon. -and who does such work himself or through his own employees, provided thausuch improve- ments arc not intended or offered for sale. If, however, the building FIXTURES - PER TRAP 5.00 S(1 FT, FLOOR AREA TOTALACREAGE GAS - EA. SYSTEM- 1 INC.4 OUTLETS 6.00 or 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 of sale.). 1, as owner of the property, am exclusively contracting with GAS - EA, SYSTEM -OVER 4 (EA.} 2.00 BUILDING USE E IND CON PB ocher INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS- 1 INC 5 V.B. 6.00licensedcontractorstoconstructtheproject (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 ASSESSORS PARCEL NO. LAWN SPRINKLERS - OVER 5 (EA.) 1.001-dcontractsforsuchprojectswith,a contractor(s) licensed pursuant to the Contractor's License Law- SEWERSANITARY STORM EA. 200ftl10.00 TRACT NO. PARCEL NO. lam exempt under Sec. B.&P.C.for this WATER HEATER WJVENT 6.OD reason Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00WORKERS' COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation !n ranee, or a certified ZONING ENG. SITE Np. copy (e . 3$00, Lab.C. Polis,No. o. ampany FIRESPRWK Y N ENERGY T-24 Y N Certified copy is hereby furnished. Certified copy is riled with the city inspection division. Applicant I MISC. - REFER TO ORD. CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. PLG. CONTR. LIC. NO. PLG. TOTAL COMPENSATION INSURANCE This section need not be completed if the permit is for one Y N Y N QTY. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars (S 100) or less.) I certify that in the performance of the work for which this per mit is issued, I shall not employ any person in any manner so as to BUILDING become subject to the Workers' Compensation Laws of California. Date Applicant. NOTICE TO APPLICANT: If, after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 PLAN CHECKemption, you should become subject 10 the Workers' Cum pensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FEEAIRHANDLINGUNIT (T010AOOGF.M) 4,00 AIR HANDLING UNIT (OVER 10MC.F.M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT( 5.00 5-00 the performance of the work for which this permit is issued (Sec. 3097, 9%.). MICROFILM HEATING UNIT LTO 100,000 B.T.U.1 8.00 GD8 HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC Lender's Name Lender's Address 1 certify that I have read is appheation and.stale that the above information is correct. I agree io comply with all city and county ordinances and slate laws relating to building construction, and VENTILATION FAN (SINGLE) 4.00 /.2.490 PLUMBING BOILER COMP (3 H.P. Dr 100,000 g:T.U,) 6.00 BOILER COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe above-mentioned property for inspection purposes. MISC. - REFER TO ORD. We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the CONST. TAXPERMITISSUANCE10.00 /©do grantin f this permit. A- MECH, CONT. LIC, NO. MECH. TOTAL JrOO LTOTAL Signa pplicant/Contractor Date OFFICE COPY