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9430 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ,�/ BUILDING PROJECT IDENTIFICATION APPLICATION Sl PERMIT PERMIT NUMBER T ADDRESS _ 9430 WILDING / f�--�-- UILDING-ELECTRICAL-PLUMBING-MECHANICAL X OWNER'a �r PLAIN CHECK VALIDATION NAME OTY. ELECTRIC PERMIT FEE D4F"e_i" PHONE CONTRACTORS NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 No. LIGHTING FIXTURES 10.00/1.00 ---� CONTRACTORS APPLIANCES-RESIDENTIAL 4.00 ADDRESS � "� /L/��s�.Ea /3/ pay PROry �l&OZ PANELS 10.00 DATE OF APPLICATION ARCHITECT PLAN CHECK FEE' P.C.N OR PANELS (OVER 200 AMP) 20.00 . ENGINEER uc.No. ISIGNS TRANS. 3.00 ADORESS ENG' SPECIALCIRCUIT - 5.00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 , APPLICANTS AoDAESS, MOTORS SEE FEE SCH. R � REss SERVICE CHANGE 20.00 F 00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 a.U 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE m G w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH, H Professions Co an my license is in full force qd 'c ❑ ❑ ❑ ey{ z O l2 - License l.r I JL�.�Lie.Number' Q w Date ( -'jj6 Contractor _ `¢ m BUILDING PERMIT ¢ IS IS 4 OWNER-BUILDER DECLARATION INFORMATION X N I hereby affirm that I am exempt from the( License MISC.- REFER TO ORD H .. o j Law for the following rectum,(Sec.7031 5,BusinessandProfessions PERMIT ISSUANCE 1000 .VALUATION $/FT. Code'.Any city or county which requires a permit to construct,alter, re ¢s-o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO, ELEC. O ¢ requires the applicant for such permit to File a signed statement that TOTAL TO he is licensed pursuant to the provisions of the Contmetor's License sir Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE i $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant toa civil penally ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars(5500)-): ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS their sole compensation,will do tie work.and the structure is not intended or offered for wk (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 FIXTURES-PER TRAP 5.00 So.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees.provided that such improve- mentsarenotmicioledorofferedforsale.lf,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 or improvement is sold withinone year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 builder will have the burden of proving that he did not build or im- BUILDING USE prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00 REs IND CON PB other . ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ licensed contractors to construct the project ISce.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Code:The Contractor's License Ww 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 conirxetovs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 the Contractors Liceme Law. TRACT NO. PARCEL NO. CII am exempt under Sce. ,B.AP.C.for this WATER HEATER W/VENT 6.00 reason Owner 'Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00 hereby air,,. that I lave a certificate of,.,,sunt to sell-insure. ZONING ENG.SITE NO. or certificate of Workers'Compenmtion Insurunes,or a cemireJ copy thereof ISec.3800- rnmy_ ,&�� p Policy ereNo. CO,Lot, Q ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 2e Z zr Y is Rld ivi th th city inspection dsion. O A p ioCentant- ,/4.d s4 MISC.- REFER TO ORD. Y 0 N Y E] IN CC w CERT1171CATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C. W COMPENSAIION INSURANCE PLG.CONTR. LIC.NO. PLG. Y[:) NYIN CL 0( This section need not be completed if the permit is (or one TOTAL hundred dollars IS 100)or Ic.J U O I certify that in the performance of the work for which this per- OTY. MECHANICARMNO5 T FEE FEE SUMMARY Id_ U mit is issued,1 shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California. UJ Date-Applicant ALTER OR ADD T ( ECFj, -�O .� 5.00 BUILDING - W NOTICE. 'f0 APPLICANTS. If,after making this Certifieale ul'Ex- Z emption,you should become subject to the Workers'Compensation qpp LIA NCE 5.00 PLAN CHECK provisions of the labor Code, you must forthwith comply with FEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT IT QF 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLINGUNIT 10 C.EMI 6.00 SEISMIC FEE 1 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,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 Lender's Address ELECTRIC 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 PLUMBING ordinances and state laws relating to building construction, and BOILER-CONK(3 H.P.or 100,ODO B.T.U.) 6.00 hereby enthoriee representatives of this city es cmcr upon thea1mveBOILER-COMP (Over 100,000 STU)SEE FEE SCH. MECHANICAL /of, A hereby Boned property tativfor spot this putty to (We) agree to save, indemnify and keep hmmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and axperues which v 9z CONST.TAX may in any way accme against said City in Consequents of the PERMIT ISSUANCE 10.00 [) grdnfl fthis permit -. MECH.CONT, LIC.NO. MECH. �4(J_� � TOTAL /� r7/ TOTAL Signatureof Applicant/Contractor Date OFFICE COPY