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13542 --,APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUI CD15V0 PROJECT I DENTI FICATI N -PERMIT NUMBER aUILOING APPLICATION & PERMIT 13542 A OP., BUILDING -ELECTRICAL-PLUMBING-MECHANICAL DW NE 'a PLAN CHECK VALIDATION NAME CITY. ELECTRIC PERMIT FEE p PHONE CONTRACTORS NA 11"'4V OUTLETS-SWITCHES-RECEP 10.0011,00 / LIGHTING FIXTURES 10.00/1.00 q uc.No. O/ CONTRACTOR 5 1 PPLIANCES-RESIDENTIAL 4.00 ADDRESS 00"0&1 V024 e ��PE / IrJ . PANELS IO.00 DATE OF APPLICATION ARCHITECT PLAN CHECK FEE P.C.NO. ) OR IPANELS (OVER 200 AMP) 20.00 ENGINEER I.I.C.No. SIGNS TRANS. 3.00 AARCOOR DDRESS ENG. - SPECIALCIRCUIT 5.00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 APPLICANTS MOTORS SEE FEE SCH. ADDRESS SERVICE CHANGE 20.00 0 0 o LICENSED CONTRACTORS DECLARATION V171ej a u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE Z (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. '^ Professions CA e m license is in full fore an�edfflectT ❑ ❑ ® ❑ 0 o,� License C ss Lic.Numbeysa3-/ _ g as w Date Contractor a Y f BUILDING PERMIT ¢ ¢ at 4 OWNER-BUILDER DECLARATION INFORMATION `x I hereby affirm that I am exempt from the Cnnlractor's License MISC.- REFER TO ORD wLLO Lawfor the following mason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 . VALUATION S/FT. �' - Code:Any city or county which requires permit to construel,xher, ac ¢G improve,demolish,or repair any Structure,prior to hs issuance,also ELEC.CONTR. LIC.NO. ELEC. a x m LL requires the applicant for such permit to file a signed statement that TOTAL Ea�TTO ITO w he is licensed pursuant to the provisions of the Comiractor's License H 2 i Law(Chapter 9(commencing with Section'7000)of Division 3 of the a Business and Professions Code)or that he is exempt therefrom and OTY. . PLUMBING PERMIT FEE ¢ _� the basis for the alleged exemption.Any violation ol"Section703L5 STORIES TYPE CONSTR. a ; by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars(S 500).): ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS their sole compensation,will do the work,and the structure is not intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 Code:The Contractor's License Law does not apply to an owner of . properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 So.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- arents are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 or improvement is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE builder will have the burden of proving that he did not build or im- RES IND CON PB Osner Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ I,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. 6.00 ASSESSORS PARCEL NO. and Professions Code:The Contractor's License Law does not apply to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a contractor(s)licensed pursuant to -SAN TORM EA.200ft110.00 the Contractor's License Law. Q TRACT NO. PARCEL NO. ❑ lam exempt under Sec,-,B.&P.C.for this WATER HEA ER W/V1�1T I 6.00 - reason Owner - Data WATER SYST 5.00 ACO.DATE ACL.FILE NO. WORKERS'COMPENSATION DECLARATION WATERT NG E 5.00 I hereby affirm that I have a certificate of consent to self-insure.. O or a certificate of Workers'Compensateggqqqqn Insurance,or u certified ZONING ENG.SITE NO. Copy Nereof(Sec.3800LabC. pamy ). Q� Policy No.rt Co hereby furnished, Q '❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T-34 Z Z ❑'Cert ificb y is filed w the�:' pe ion vision. O Applicant /J' _ �.r p,u. / MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑' Fy =7.. PERMIT ISSUANCE 10.00 - FLOOD ZONE A.L.U.C. LU CERTIFICATEOFEXEMPTION FROM WORKERS' W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. /O_74P d Y❑ NEI Y ❑ N❑ O (This section need not be completed if the permit is for one TOTAL �C =) Z hundred dollars IS 100)or less.) U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL I- mit is issued,I shall not employ any person in any manner so as to U become subject to the Workers'Compensation Laws of California. O n Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } Do NOTICE TO APPLICANT: If,after making this Certificate of Ex- F,,, Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith Comply wide FEE fJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE 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% . HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM 3097,Civ.CJ. Lender's Name Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC . 1 certify that I hove read this application and state that the above VENTILATION FAN (SINGLE) 4.00 �0 Ov information is correct.I agree to comply with all city and county PLUMBING ordinances and stale laws relating to building construction, and BOILER-COMPI3H.P.or t00,000B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned properly for inspection purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which CONST.TAX may in any way accrue again t said C" in consequence of the PERMIT ISSUANCE 10.00 gmnli of this perryyy.P MECH.CONT. LIC.NO. MECH. Z�,�cv/J��/f'iJ TOTAL TOTAL Signature of Applicant/Cognature of Applicant ractor��DateI OFFICE COPY _