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91481 A APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING -ELECTRICAL- PLUMBING -MECHANICAL PERMIT NUMBER 9148 BUILDING ADDRESS Christen so -A) DR. OWNER'S NAME b41e_ TpD eOk Yf 996-/457 �Q AI PRONE OTV. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION NAMEERActoRs UTLETS- SWITCHES -RECEP .4000/1.00 jr ' LIC. No. LIGHTING FIXTURES 10.00/1.00 ADDRESSTOR's APPLIANCES - RESIDENTIAL 4.00 PANELS 10,00 PHONE - DATE OF APPLICATION ARCHITECT OR ENGINEER LIc. No. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE C. NO. SIGNS TRANS. 3.00 ADDRESS E.G. SPECIALCIRCUIT 5.00 PERMIT VALIDATION TEMP. METER OR POLE INS. 20,00 ' ZIP APPLICANTS- ADDRESS MOTORS SEE FEE SCH. " SERVICE CHANGE 20.1 6 ���5 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 1000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class Lie. Number Date Contractor 155 ANCE GATE BLDG. ELECT. PLG. MECH. e ❑ ®, ❑ £j 1 s� City O Cupe OWNER -BUILDER DECLARATION 1 hereby affirm that 1 em exempt from the Contractor's License Law for the following reason. (Sec. 7031.5, 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 exempt therefrom and BUILDING PERMIT INFORMATION MISC.- REFER TO ORD PERMIT ISSUANCE15 VALunnON ELEC. CONTR. LIC. NO. ELEC, // W TOTALb �- GTY. PLUMBING PERMIT FEE PERMIT TO v_s � V_ E / LLC STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.$ 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'" O 1, as owner of the property, or my employees with wages as 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. 5.00 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. 'ments are not intended or offered for sale. If, however, the building F IXTUR ES - PER TRAP !JOQ OL GAS-EA.SYSTEM-11NC.40UTLETS 6.00 SD. FT. FLOOR AREA TOTAL ACREAGE 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- pr5e 1, asofor neeose of sated' I, as owner of the property, exclusively contracting with GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 BUILDING USE RES IND CON PB OINPr 0 ❑ 0 ❑ INDUSTRIAL WASTE INTER. 30.00 the project (Sec. 7044, Business he licensed contractors to The to antr owner of property who builds improves Thereon, and who - LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 LAWN SPRINKLERS -OVER 5 (EA.1 1.00 ASSESSORS PARCEL NO. tr contracts for -such projects with a contractos(s) licensed pursuant to the Contractor's License Law. SEWER V -ST . 200ft/10.00 TRACT NO. PARCEL NO. ❑ tont exemp under Sec. ,B.&P.C. for this reason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC. GATE ACO FILE NO, WATER TREATING EQpU�IP, 5.00 WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance, or a certified CSV O ZONING ENG. SITE N0. copy thereof (Sec. 3600. Lab.CJ. Policy No. Company ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the city inspection division. Applicant FIRE SPRINK Y ❑ N ENERGY T-24 Y NC3 REFER TO ORD. CERTIFICATF. OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE -1890 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[] GTY. 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 ALTER OR ADD TO MECH500 . . NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption, you should become subject to the Workers' Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FEE AIR HANDLING UNIT (TO 10ACDC.F:M) 4.00 AIR HANDLING UNIT (OVER 10=1C.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm that there is aconstruction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 the performance of the work for which this permit is issued (Sec. MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC Ic Names Lender's Name Lender's I certify that 1 have read this application and state that the abovefo information is correct. I agree to comply with all city and county grdinareas and state laws relating to building constructinn, and hereby authorize representatives of this city to enter upon The above-mentioned property for inspection purposes. VENTILATION FAN (SINGLE) 4.00 PLUMBING (N BOILER-COMP(3 H.P,or100,000B.T.U.) 6.00 BE ER (over 100,000BTU)SEE FEESCH. MECHANICALS MISC. - REFER TO ORD. CONST. TAX (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any ay accrue against said City in consequence of the olio of Ihk arm yYpC g g�j PERMIT ISSUANCE 10.00 MECH. CONT. LIC. NO. � MECH. TOTAL TOTAL Q� natureof At actor Uate OFFICE COPY