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13541 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY '•" BUI LDI NG PROJECT 1 DENTI FICATIOPERMIT NUMBER BUILDING APPLICATION & PERMIT 13541 OO 9A.V G/j/ BUILDING—ELECTRICAL—PLUMBING—MECHANICAL OWNER'S PLAN CHECK VALIDATION NAME QTY. ELECTRIC PERMIT FEE (�K (IfiJW, PHONE CONTRACTORS NAME UTLETS-SWITCHES-RECEP 10.0011.00 C p / Lc.No. A-4, 1LIGHTING FIXTURES 10.00/1.00 CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 ADDPE/55 ' Q D / t Y / PHONE -15, PANELS 10.00 DATE OF APPLICATION OR RCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO. ENGINEER LIC.No. SIGNS TRANS. 3.00 AARCH.OR DDRESS ENG SPECIAL CIRCUIT 5,00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 ATs - MOTORS SEE FEE SCH. -4lzeu t�J ADDRESSDOREss SERVICE CHANGE 20.00 7/L7 Ceti CONTRACTORS DECLARATION A ¢U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE 2 w (commencing with Section 7000)Of Division 3 Of the Business and BLDG. ELECT. PLG. MECH. m i Professions Cod an y ense is in full fort a e t. G i u� w ' icense�/ass Lic.Number ❑ ' ❑ ❑ Dale�v12��Contractor Q y s J - BUILDING PERMIT ¢ ¢ w 0 OWNER-BUILDER DECLARATION INFORMATION o P. " MISC.— REFER TO ORD in; r I hereby affirm That I am exempt from the Contractor's License u o¢ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT. ry Code:Anycity orcounty which requiresa permit to construct,alter, a in Q improve,demolish,or repair any structure,prior t0 its issuance,also ELEC.CONTR. LIC.NO. ELEC. La iL D¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT,TO wAH w he is licensed pursuant to the provisions of the Contractor's License !, Hi > Law(Chapter 9(commencing with Section 7000)ofDtvision 3 ofthe LT a Business and Professions Code)or that he is exempt therefrom and PLUMBING PERMIT FEE ¢ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant loo civil penalty ALTER-DRAIN IEA.) 5.00 of not morn than five hundred dollars($500L): ❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 DCC.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,AREA,COND. 5.00 Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work /- F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provt, it that such improve- ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INCA OUTLETS 6.00 or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE builder will have the burden of proving that he did not build or im- RES IND CON PB Omer prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ 1,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 ars owner of properly who builds or Improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a contractors)licensed pursuant to the Contractor's License Law. SEWER-SANITARY- A.200ft/10.00 TRACT NO, PARCEL NO. ❑ I am exempt under Sec. ,BAP.C.for Ibis WgTER HEATER W/VENT 6.00 reason Owner Date WATERSYSTEM 5.00 S^ ACC,-DATE ACC,FILE NO. WORKERS'COMPENSATION'DGCLARATION WATER TR EATIkAf QUIP. (� 5.00 I hereby affirm ns that I have a certificate ul'coent to self-insure, Up ZONING ENG.SITE NO. or a certificate of Workers'Compensation I surance,or a certified copy lher•^f t ce rid Policy NoV_ am any 0 ❑ Certified copyR ereby famished. - FIRE SPRINK ENERGY T 24 Z Z' ❑ Certified cap filed with cit9 itior clivi' n. O Applicant ( - /� MISC.- REFER TO ORD. v❑ N❑ v ❑ N❑ it y� CERTIFICATE OF EXF:MPTIORKCRS' PERMIT ISSUANCE 10.00 f�J�� FLODo zoNE A.L.aC. LUQCOMPENSATION INSURANCE: PLG.CONTR. LIC.NO. TOTAt,/ Q Y❑ N❑ Y❑ N❑ CL Z (This section need not be completed if the permit is for one hundred dollars($100)or less.) U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL mit is issued,I shall not employ any Person to any manner m as to U become subject to the Workers'Compensation Laws of California. y Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } N NOTICE TO APPLICANT: If,after making this Certificate of Ex- F. ? emplion,you should became subject to the Workers Compensation APPLIANCE _ 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10AWC.F.M.) 4,00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.RM.) 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. MICROFILM 3097,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)Leader's Address ELECTRIC p 1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 dy information is correct. I agree to comply with all city and county PLUMBING 16a ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the above-mentioned properly for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL (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,against said I consequence of the PERMIT ISSUANCE 10.00 g4rant of this permit MECH.CONT. LIC.N0. MECH. TOTAL TOTAL "Go are of APPlican Cnntr or U OFFICE COPY