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10256APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY i3U1 LDI NG PROT I DENTI FICA APPLICATION & PART10256 BUILDING — ELECTRICAL— PLUMBING — MECHANICAL PERMIT NUMBER aDIL OWN NAM PNONE OTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION - DATE OF APPLICATION NT rc+ACO's .y syn No. UTLETS-SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 1,0 TR ADOR On PPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 OR RITECT ENGINEER LIC. NO. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE .C. NO. ISIGNS TRANS. 3.00 AACHOR ADDRESS ENG. ZIP SPECIAL CIRCUIT 5.00 PERMyjyr�+ON iiillJ il/l AI A �(�pC JRIV '3 986 City of Cupertino ISSUANCE DATE BLDG. ELECT. PLG. MECH ❑ ❑ ❑ EMP. METER OR POLE INS. 20.00 A unrs MOTORS SEE FEE SCH. SERVICE CHANGE 20,00 LICENSED CONTRACTORS DECLARATION I hereby affirm that I ore licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busin and Professions Code Iiccnsa ,s in lull fore" License Class_ Lie Number Dale Contractor OWN- -B.exe pt fro theC N I hereby affirm that I am exempt from the Contractor s License Law for the following mason.(Sec. 7031,5. Businnsand Professions Code: Any city or county which requires a Permit to construct, alter, improve, demolish, or repair any structure, prior to its i tuunce, also requires the applicant for such permit to the a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Sect ion 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Sect ion 7031.5 by any appbcanl for a permit subjects theapplicant toa civil Penally of not mom than five hundred dollars (55(0).): ❑ 1, as owner of the property, or my emptoyms with wages as their sole compensation, will Jo the work, and the structure is not intended or offered for sale (Sec. 7044,Business and Professions Code: The Contractor's License Law docs 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 oroffered for sale.. If, however, the building 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 J' ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Lew does not apply to an owner of property who builds Or improves thereon, and who contracts for such projects with a cofn uctods) licensed pursuant to the Contractors License Law, ❑ I am exempt under See. ,B.&P.C. for this reason TEMP. POLE 30.00 BUILDING PERMIT INFORMATION MISC. — REFER TO ORD PERMIT ISSUANCEVALUATION 10'00 $/FT. ELEC. CONTR. LIC. NO. ELEC TOTA.L PE IT TO OTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR, ALTER -DRAIN & VENT -WATER (EA.) 5.00 BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA COND. 5.00 FIXTURES - PER TRAP 5.00 GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 SO. FT. FLOOR AREA TOTAL ACREAGE GAS - EA. SYSTEM -OVER 4 IEA.) 2.00 BUILDING USE RIND CON PB Omer Es 11 ❑ ❑ ❑ INDUSTRIAL WASTE INTER'. 30,00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASs SSORg PARCEL NO. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO, PARCEL NO. WATER HEATER WNENT 6.00. Owner Date WORKS RS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self -insure, or a certificate Df Workers' Com Pensation umnce, or geertifed COPY thcr 0� C.1. (/.�� Policy /�ry VA -t. coPY IS hereby furnished Certifrcd <o file h t of inspection division. AP sent WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 ZONING ENG. SITE NO. FIRE SPRINK V N � ENERGY T -Z4 V NE] � MISC.- REFER TO ORD. CERT ICA F.OF Ex1 AFT' FROM WORKERS' COMPENSATION INSURANCE (This section need not he completed if the permit is for one hundred dollars ($ 100) or Icss. ) 1 certify that in the performance of the work for which this per- mit is issued, 1 shall not employ any person in any manner an as or, become subject to the Worked Compensation Laws of California. Dale Applicant PERMIT ISSUANCE 10.00 FLOOD ZONE Y [] N� I A.L.U.c. V NE] PLO CENTS, LIC. NO. PLG. TOTAL QTY MECHANICAL PERMIT FEE FEE SUMMARY BUILDING ALTER OR ADD TO MECH. 5.00 NO'r1Cli TO APPLICANT: If, after making this Certificate of Ex- emption, you should become subject to the Workeri Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this Permit shall he deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the paformenro of the work for which this purrnit is issued (Sec.OFILM 3097, Civ.C.). Lender's APPLIANCE 5.00 AIR HANDLING UNIT (TO 10)000C.F.M) 4.00 PLAN CHECK FEE AIR HANDLING UNIT(OVER 10)=C.F.M.)6.00 SEISMIC FEE EXHAUST HOOD (WITH DUCT) 5.90 HEATING UNIT (TO 100,000 B.T.U.) 8.00 Name Lender's Address HEATING UN IT (OVER 100,000 B.T.U.)9.50 ELECTRIC I certify that l have read this application and state that the ahoy information is correct. I agree to comply with sell city and count ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for ins ec I purpuus. (We) agree to inde Ify nil keep hamrlL-ss the City of Cupertino again a ilic , jud its, costs and expenses which may ve true again said City in consequence of the Pg [h x, [vIe AppIrs" n {Coractor am VENTILATION FAN (SINGLE) 4,00 BOILER -COMP 13 H.P. Or 100,000 B.T.U.) 6.00 PLUMBING BOILER -COMP (Oxer 100,000 BTU) SEE FEE SCH. MECHANICAL MISC. - REFER TO ORD. CONST. TAX ERMIT I LANCE 10.091 ME ENT. LI . N0. MECH. TOT TOTAL OFFICE COPY