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3753APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT VM-IRNLY BU LDI NG PROJECT I DENTI FICATI ON OFFICE APPLICATION & PERMIT PERMIT MBER BUILDING ADDRESS �I �f• BUILDING•—ELECTRICAL— PLUMBING — MECHANICA 1 t� 33 75 PLAN CHECK VALIDATION ' JUN 9 �� OWNER' . 'ry ���_`/ "sM.y JD E TY. ELECTRIC PERMIT FEE NAMEpAcroRs OUTLETS -SWITCHES -RECEP 5.00/1.00 LIGHTING FIXTURES 5.00/1.00 LIC, No. " City of Cupertino CONTRACTORS ADDRESS - PPLIANCES- RESIDENTIAL 4.00 -` PANELS 5.00 PHONE DATE OF APPLICATION ARCHITECT OR SIGNS 6.00 PLAN CHECK FEE P.C. N0, ENGINEER LIC. No. SIGNS TRANS. 3.00 ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION rEMP. METER.OR POLE INS. 15.00 GIP APPLICANTS uO,q�l(��g AD R s5 MOTORS SEE FEE SCH. 2Z _ SERVICE CHANGE 10.00 LICENSED CONTRACTORS DECLARATION _k3 I hereby affirm that I am licensed under pinvisioms of Cheptcr9 (commencing with Section 7000) of Division 3 of the Business enA Professions Code, and my license is in lull force and effect License Class Lie. Number ISSUANCE DATE & BLDG. ELECT. ❑ I PLG. MECH. ❑ ❑ Data 'Contractor UILDING PERMIT qq"MATION - '- OWNFR-BUILDER DECLARATION I hereby affirm that I am 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 smtement that he is licensed pursuant To the provisions of the Contractor's License Law (Chapter 9 (commeneingw'ith Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therchom and MISC. — REFER TO ORD VALUATION SIFT. PERMIT ISSUANCE .6.00 ELEC. CONTE. LIC. NO, ELEC. TOTAL PE T TO QTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR_ the basis for Ute alleged exemption. Any riolation of Section 7031.5 by any applicant for a permit subjects the applicant IN a civil penalty of not more than five hundred dollars (S500y): ALTER -DRAIN & VENT -WATER (EA.)4.00 O[ 1, as owimr of the property, or my employees with wages a, th a sole compensation, will do the work, and the ,structure is not BACK F LOW PROTECT.' DEV ICE 2.00 oec. caouP BEs. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 4.00 intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work FIXTURES - PER TRAP 4.00 SO. FT. FLOOR AREA TOTAL ACREAGE himself or through his own employees, provided that such improve- mentsare not intended or offered for sale If. however, the building GAS -EA. SYSTEM- 11NC. 4OUTLETS 4,00 or improvement is sold within one yen of contpletimti the owner- build,, will have tire burden of proving That he did not build or int - prove lof sale.). h as ownernee of the properly, am exclusively contracting with 1. aso . GAS - EASYSTEM -OVER 4 (EA.) 1.00 - BUILDING USE IND CON PB Omer E-1 El ❑ El INDUSTRIAL WASTE INTER. 20.00 licensed colons od to construct the project (Sec. does Business o I Professions Code: The Contractor's License Law docs not who tothereon, and who toanowner of property who builds LAWN SPRINKLERS - 1 INC 5 V.B. 5.00 - LAWN SPRINKLERS -OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. , trimproves the Cone for such projects with a cont racnvf xl licmised pursuant m the Contractor's License Law, SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT No: PARCEL No. ❑ am exempt muter See ;T&P.C. for this 'reason WATER HEATER W/VENT 4.00 Date Owner WATER SYSTEM 4.00 ACC.DATE ACC. FILE NO. WATER TREATING EQUIP, 4.00 WORM, RS'COMPENSATION DECLARATION I hereby affirm that 1 have a ceniticme or consent to self none. car a ecitificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. - copy thereof (Sec. 3800. Lab.C.). Policy No. Coupany FIRE SPRINK Y ❑ N ❑ ENERGY T 24 Y ❑ N❑ ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the city inspection division. Applicant MISC. - REFER TO ORD. CERTIFICA'I'Ii 0171 XEMPFICON 17ROM WORKERS' ' PERMIT ISSUANCE - B.00 - FLOOD ZONE A.L.U.C, PLG. CONTE. LIC. NO; PLG. TOTAL COMPENSATION INSURANCE (This section need not be copleted if the permit is for one m Y ❑ N❑ Y ❑ N❑ CITY. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars (S I00) or less.) I ecNily that in the p"knirman'S of The work for which this per. mit is issued, I shill not employ any person in any t cr so as to becoic bycd,y�the Worked nrpene - nLuw of ITnits. Datcf�4/_�af—Applicant NOTICE TO APPLICANT: after making this Cl Ificate up Ex- BUILDING ,rye �• p ALTER OR ADD TO MECH. 4.00 APPLIANCE 4.00 PLAN CHECK emption, you should become subject m the Workeri Compensation provisions of the Labor Code, you must forthwith comply with such provisions ar this pmrrnit shall he Aceosd revoked. AIR HANDLING UNIT (TO 10)000C.F.M.) 3.00 FEE ' AIR HANDLING UNIT(OVER 10=C.F.M.15.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY EXHAUST HOOD (WITH DUCT) 2.00 I hereby affirm that there is a construction lending agency for the performance of the work for which this Renoir is issued (Sec. 3097, Civ.C.). MICROFILM HEATING UNIT ITO 100,000 B.T.U.) 4.00 H EATI NG UN IT (OVER 100,000 B.T.U.)7.50 ELECTRIC Lender's Name Lender's Address nd state that the above I certify that I have read this application an'" information is correct. 1 agree to comply with all city and country' ordinances and late laws relating to building construction. anJ VENTILATION FAN (SINGLE) 3.00 PLUMBING - BOILER-COMPI3H.P.or100,000B.T.U.) 4.00 BAILER -COMP IOvA, 100,000 BTU) SEE FEE SCH, MECHANICAL hereby authorize representatives of this city to enter upon the above mentioned property for inspection Purim.,. MISC. - REFER TO ORD. ' CONST. TAX (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses whichPERMIT may in any way acenle against said City in eonscqucnce of the ISSUANCE - 3.00 MECH. CONT. ' LIC. NO. MECH. gra 'ng of this permit. - TOTAL TOTAL lTD Si ut re fA ,Lot Rrect., Due �— OFFICE COPY,