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8193APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY BU LDI NG PROJECT 1 DENTI FICATI ON APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING -MECHANICAL PERMIT NUMBER ^ t� � aUILDING ADDRESS <d�-39 Al O ER$ PLAN CHECK VALIDATION NAME QTY. ELECTRIC PERMIT FEE ONE CTOF -s NAME NAME uc. rvD. OUTLETS-SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 ,bra - .ADDRESS o 's APPLIANCES --RESIDENTIAL 4.00 PANELS 16.06 PHONE DATE OF APPLICATION A CHITEC OR ENGINEER uc. No. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ADDRRESS ENG. SPECIALCIRCUIT 5.06 PERMIT VALIDATION EMP. METER OR POLE INS. 20.00 ZIP APPLCANT'S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00J p �.., LICENSED CON1' RACTORS DECLARATION TEMP. POLE 30.00 I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE (commencing with Section 7000) of Division 3 of the Business and I, ... Dismiss Codc, and n license is in full for; and effect. License Clas' LiI n �' BLDG. ELECT. PLG. MECH. m Date Contrac r BUILDING PERMIT WNER-BUILDF,R DECI RATION I hereby affirm that I am exempt front the Contractor's License Law for the following reason. (Sec. 7031.5, Business and Professions Code Any city or county which RAILResa permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant torsuch permit to file a signed statement that fie is licensed pursuant to the provisions of tie Conlmetoi s License Law (Chapter 9(commeneing with Section 7000) of Division 3 of Ote/"yrL Business and Professions Code) or that he is exempt therefrom and INFORMATION MISC.- REFER TO ORD vgLllATION $/FT. PERMIT ISSUANCE 10.00 ELEC. CONTR. LIC, NO. ELEC. TOTAL PERMIT TO S 'VG1.� QTY. PLUMBING PERMIT FEE STORIES TYPE eONSTR. the basis for the alleged exemption. Any violation o'Section 70315 1 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): C 'I- - ALTER -DRAIN & VENT -WATER (EA.) 5.00 ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do Ore 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 I'nn sale (Sea 7044, Business and Professions Code. The Contractor's License Law docs not apply to in owner of property who builds at improves thercom and who docs such work R-3 FIXTURES - PER TRAP 5.06 SO. FT. FLOOR AREA TOTAL ACREAGE himself or through his own employees, provided that such in] Prove- ments are not intended or offered for sale. If, however, the building GAS-EA.SYSTEM-11NC.40UTLETS 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 ofsale.), CI 1, as owner of the properly, am exclusively contracting with GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 BUILDING USE RES IND CON PR Omer © ❑ - ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. licensed contractors to construct the pntject (Sec. 7044, Business and Professions Cade: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who LAWN SPRINKLERS - OVER 5 (EA.) 1.00 contracts for such projects with a conlractods) licensed pursuant to the Contractor's License Law, SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑ I amexempt under Sec. ,B.&P.C. for this reason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 wORKERS'COMPENSA'I' ION DECLARATION 1 hereby affarn that I have a certificate of consent to sell' -insure, Or a ;crtlfteate Of workers Compenedu n Insurance, or a certified ZONING ENG. SITE NO. G^ copy thereof(Sec. 3800. Lah.CJ_ ,Ill J Policy No. Company /Ill J FIRE SPRINK Y ❑ N❑ ENERGY T-24 Y ❑ ,N❑ ❑ Certified co yis hereby fumi;hed. ❑ Certif•d c py is filed wib the city iipm r d",con. Applicant MISC.- REFER TO ORD. EOPP plvff FROM WORKERS' CETood PERMIT ISSUANCE 10.00 FLOODZONE A.L.uc, PLG. CONTE. LIC. NO. PLG. TOTAL MPEN ATIO SURANCE This senut be conrpleled if the permit is I'or one Y ❑ N❑ Y ❑ N❑ hundred dollars ($100) or 1.1.) 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 QTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING Co fv become subject to the Workerx'Compensation Laws of California. Dam ApplioamALTER OR ADD TO MECH. 5.00 NOTICE TO APPLICANT: If, after making this CeRifiwtc of It NOTICE APPLIANCE 5.00 PLAN CHECK youshould become subject to the Workers'Compensation provisions of lire Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FEE AIR HANDLING UNIT (TO 10,006C.F.M.) 4.00 AIR HANDLING UNIT (OVER IQOOOC.EM.) 6.00 SEISMIC FEE j3 37 CONSTRUCTION LENDING AGENCY 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. 3097,Civ.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATING UNIT (OVER 100,000 B.T.U.) 9.50 ELECTRIC Lender's Name NamAdifirc Lender's ss I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 information is correct I agree to comply with all city and county oodnances and afar, laws relating to building construction, and PLUMBING BOILER-COMP13 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP IUVer 100,000 BTU) SEE FEE SCH. MECHANICAL u hereby authorize representatives of this city to enter upon the a bovc-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 mayJn any way acerae painst said City in consequence of the CONST. TAX PERMIT ISSUANCE 10.00 grarfrm of flu c Pen»tf ' MECH. CONT. LIC, N0. [TOTAL TOTAL �dd 1�7 Sty eo Ap- cant/C tacto DI e // /•/ INSPECTOR COPY