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6884APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 13UI LD1 NG PROJECT I DENTI FICATION APPLICATION & PERMIT BUILDING -ELECTRICAL- PLUMBING -MECHANICAL PERMIT NUMBER 6884 BUILDING / ADDRESS IOO� I ^. II OWNER'S NAME ��J� E-LLICt INS oxfT �C,,ONE OTY. ELECTRIC PERMIT' FEE PLAN CHECK VALIDATION DATE OF APPLICATION CONTRACTOR NAME NAME n ' I -gjj'(rr1C.oJE�.'KA R.Nlfsbu`111 O. UTLETS- SWITCHES -RECEP 5.00/1,00 LIGHTING FIXTURES 5.00/1.00 ADDRESS DR'S CONTRACTORS ! 22938 AvI tc O��L. PH1ONE qJ,S- I APPLIANCES - RESIDENTIAL 4.00 PANELS 5.00 ARCHITECT HAJE4r. IYI OR ENGINEER - uc.No. SIGNS 6.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ARCH. OR ENc. ADDRESS SPECIAL CIRCUIT g,QQ PERMIT VALIDATION rrEMP. METER OR POLE INS. 15.00 - ZIP APPLICANTS ADORE s MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 LICIiNS1]D CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Bllsln0'a and PruICSSiana Code, and Irl limen In Is 111 full fume un eltecl License Class _. LiaNwnber_ Date_��L- Contract., ISSUANCE DATE BLDG. ELECT. ❑ ❑ PLG. MECH. ❑ BUILDING PERMIT • OWNER-BUILDFR DECLARATION I herebyffrRi that I am exempt from the Contractor's License a P Law for the ityfollowing reason. (Sea 7uresa Businessand Professions alter, Code: Any miry or county which requirese permit to its m ifs issuance, also improve, ire plic or for Sir any straCto ti e,i signed req Gina thedp urstia for such permit to ❑Ic a sConJ actor's i that pursuant to hC provisions of the Contractor's Livnur he is (Chapter Low (Cha nd Professions therefion o and tile and Professions Code) o, that lie i is exempt ecrcfrom and Codeng with Section is 00) exempt the basis far (he alleged exemption. Any violation Of Section 7031.5 tire basis INFORMATION MISC. - REFER TO ORD VALUATION $/FT. PERMIT ISSUANCE 6.00 ELEC. CONTR. LIC. NO. TOTAL TOTAL PERMIT TO DTV. PLUMBING PERMIT FEE STORIES TYPE CONSTR. ALTER -DRAIN & VENT -WATER (EA.) 4.00 by any applicant for a permit subjects the applicant loo civil penalty of not more than five hundred dollars f$500).1: ❑ I, as owner of the property, or my employees with wages as their sale compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions BACK FLOW PROTECT. DEVICE 2.00 OCC. GROUP - RES. UNITS C DRAINS -FLOOR, ROOF, AREA, COND. 4.00 Code: The Contractor's License Law does not apply to an owner of pnrperty who builds or Improves thereon, and who does such walk FIXTURES - PER TRAP 4.QQ SO. FT. FLOOR AREA TOTAL ACREAGE himself or through his own employees, provided that such improve- mentsare out intended oroffered for Sale. If, however, the building GAS - EA. SYSTEM - I INC.4 OUTLETS 4.00 or improvement is Sold within one year of completion, the owner- builder will have the burden of -proving that he did not build or am- prove for purpose nfzale.). ❑ I, as owner of the property, am exclusively contracting with licensed c retractor, to construct the project (Sec. 7044, Business GAS- EA- SYSTEM - OVER 4 (EA.) 1.00 BUILDING USE RES IND CON PB Omar ❑ ❑ El1:1 ❑ INDUSTRIAL WASTE INTER._ 20.00 LAWN SPRINKLERS - 1FINC.5IV.B. 5.00 ASSESSORS PARCEL NO. and Professions Code: l'he Conl,,chu's License Law docs 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 it coninctor(s) licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORIf& A. 200f[/8.00 TRACT NO. PARCEL NO. WATER HEATER W/VENT 4.00 ❑ [am exempt under SBC. ,B.&P.C. for this reason Owner Date WATER SYSTEM Qt Vt1 IL w4.00 �'>•' •� ACC. DATE ACG FILE NO. WORK 17RS'COM PENSA'MON DECLARATION WATER TREATING EQUIP. 4.00 s hereby affirm that 1 have a certificate of consent to sell' -insure. or a certillcale of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy the,l -0101.3IS"380Q rpany-Me gC� Tolley L6opy Company FIRE SPRINK ENERGY TQ4 �T'CetlilleJ ropy is hereby famished. cr ❑ Certified copy is fled with the city inspection division. Applicant v ❑ N❑ N v ❑ ❑ MISC.- REFER TO ORD. PERMIT ISSUANCE 6.00 (D.- FL000zo NE A.L. u.C. CERTI14CATF OF Iia F,MPFION FROM WORKERS' L T I LIC D. PLG. 1Z� TOTAL (This rectirin neednotb TCompleted)liC he-pernriUis I'ar Beo Y ❑ N❑ Y ❑ N❑ DTV. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars IS 100) Or less.) I certify that in the performance at the work which his per- mit is issued, 1 shall not employ any person in any manner w as to become subject to he Workers' Compensation Laws of California. Date Applicant BUILDING ALTER OR ADD TO MECH. 4.00 NOTICE '10 ApPLICANT: If, after making this Certificate of fix- option, you Shodd become subject In the Workers Compensation provisions of the Labor Code, you Bruit forthwith comply with such poilemons or this permit shall be dinned revoked. _ APPLIANCE 4.00 PLAN CHECK FEE AIR HANDLING UNIT (TO 10,000C.F.M.) . 3.00 AIR HANDLING UNIT(OVER 10J000C.F.M.) 5.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY EXHAUST HOOD (WITH DUCT) 2.00 MICROFILM I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097. Cie C.I HEATING UNIT (TO 100,000 B.T.U.) 4.00 HEATI NG UN IT (OV ER 100,000 B.T.U.P.50 VENTILATION FAN (SINGLE) 3.00 ELECTRIC Lender's Nm [ Lender's Andres> - I cenify that 1 have read this applicmion and Store that the above information is correct. I agree to comply with all city and county ordinand state laws relating to building construction, and ances PLUMBING �U �a 6 BOILER-COMP(3 H.P. or 100,000 B.T.U.) 4.00 BOILER -COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL _ .hereby authorise representatives of this city to enter upon the above-mentioned property for inspection purposes. misc.- REFER TO ORD. CONST. TAX (We) agree to Savo, indemnify and keep harmless the City of Cupertino gains[ lis 'lines, judgments, costs and expenses which may it n way c c against Said City in consegoenc, of the gonlln I. c Ii 7I, ( / OTTT PERMIT ISSUANCE 3.00 MECH.CONT. LIG NO.MECH. TOTAL TOTAL azure (Applicant/Contractor Date OFFICE COPY /