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2173APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONL BUILDING PROJECT IDENTIFICATION APPLICATION &PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL P NUMBER 217 3 mJ LING OWNER'S NA OTY. ELECTRIC PERMIT FEE PLANCHECK VALIDATION /j��p� ON 'enmE .CgoR a. OUTLETS-SWITCHES-RECEP 5.00/1,00 LIGHTING FIXTURES 5.00/1.00 uc. No. DATE OF APPLICATION CONTRACTOR'SPPLIANCES AooREas PHONE - RESIDENTIAL 4.00 PANELS 5.00 ARCHITECT OR ENGINEER u LIC rv0. SIGNS 6.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ARCH. OR ENG. - ADDRESS ., ZIP SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ' ry /T / TEMP. METER OR POLE INS. 15.00 APPLICANTS ,. A CODEss n " - MOTORS SEE FEE SCH. SERVICE CHIA 0,00 LICENSEDCON'FRACTORS DECLARA1 ION 0 1 hereby affirm that I at. licensed under provisions of Chapter) (commencing with Section 7000) of Division 3 of the business and Plofe5sion5 Code, and my license Is In full force and of feel License Class LiC. Number - Date C'onlrector ISSUANCE DATE 1982 BLDG. ❑ ELECT.1 11❑ PLG. I MECH, {�j A,1L111 1�'iS�.4Y BUILDING PERMIT OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License. Law forlhe followiugreuson.(Sec. 7031.5. Business;ad Professions INFORMATION MISC. - REFER TO ORD vALUATION S/FT. PERMIT ISSUANCE 6.00 Code'. Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also ELEC. CONTE. LIC. NO. ELEC. requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO he is licensed pursuant to the pmvlsions of the Conlnm[ois Limnsc Law (Chapter 9 (commencing with Section 7000) of Ilivision 3 of the Business and Professions Code) or that he isexempt therefrom and the basis for the alleged exemption. Any violation of Section 70315 by any applicant for a permit subjects the applicant to r,wil penalty of not are than five hundred dollars (8500).): - DTV. PLUMBING PERMIT FEE STORIES TYPE CONSTR. gLTER-DRAIN-WATER IEA.14.00 BACK FLOW PROTECT. DEV ICE 2,00 OCC. GROUP RES. UNITS ❑ 1, as owner of the property, or my employees with wages us their Sole compenvtion, will do the work, slid the structure Is not intended or offered for sale (Sec. 7044, Business and Professions DRAINS -FLOOR, ROOF, AREA,COND. 4.00 Code: The Contractor's License Law dour not apply to an owner of property who builds or improves thereon, and who docs such work himself or through his own employees, provided that such improve - •lit', are not intended or offered for sale. If, however, the building FIXTURES - PER TRAP 4.00 SO. FT.FLOORAREA TOTAL ACREAGE GAS-EA.SYSTEM-I1NC.40UTLETS 4,00 ;provenrent is sold within one year of completion, the owner- builder will have the burden of proving flat he dirl not build ur fill- prove for purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Sec 7044, Business GAS - EA. SYSTEM - OVER 4 (EA.) 1.00 - BUILDING USE ' RES IND CON PB Omer ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 20.00 LAWN SPRINKLERS - 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. and Professions Codc: The Contracloi s Licmisa Law does mol apply to an owner of property who builds or improves thereon. and who LAWN SPRINKLERS -OVER 5 IEA.I 1.00 contracts for such projects with a contractor(s) licensed palSllarll to the Contractor's License Law. I SEWER -SANITARY -STORM EA. 200ft/8.00 TRACTNO. PARCEL NO. WATER HEATER W/VENT 4.00 ❑ 1 ail exempt un der Sec. ,b.&P.C. Iirr this Henson Date Owner WATER SYSTEM 4.00 ,CC. DATE ACC. FILE NO. WORKERS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 4.00 I hereby affirm that l have it certificate of consenl to Sell -insure; or a certificate of Workers' Compensation Insurance, or u certltied ZONING ENG. SITE NO. copy thereof (Sec. 3800, Lab.C.). No. Company Policy ❑ (.'CrIiICd Capy f'herCby 11f1116h L`d. ❑ Certified copy is Cited with -the city Inspection division' Applicant FIRE SPHINK Y❑ N❑ ENERGY T-20 Y❑ N❑ MISC.- REFER TO ORD. CIi R'I'IFICA'1' li Of' EXEMPTION PROM WORKERS' COh1PIiNSA] ION INSURANCE ('[his Section need not be completed it the permit is I'or uric - PERMIT ISSUANCE 6.00 "a"FLooD ZONE 'Y ❑ N ❑ - A. L. u.c. Y ❑ N ❑ PLG. CONTR. LIC. NO.TOTAL CITY MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars IS 100) or IcYv) I certify that in the performance of the work for which this per- Intl Is IlSoel, 9lla l "'It emptoy m parX(11 SII any IIIImn.r Sa a%la to the Worker; -I penf nLawsr' .. Applicant APPLICANT: If, after akmg s etlifica of Ex- emption, youd uuld become subject to the rkers ,rep nsalion provisions of the Labor Code, you Inust rlIWHII - ply with tsuchprovisions or this permit shall be dccnwd revoked. BUILDING ALTER OR ADD TO MECH. 4.00 App LIANCE 4.00 PLAN CHECK FEE AIR HANDLING UNIT (TO IODOOGF.M.) 3.00 AIR HANDLING UNIT OVER 10MC.F.M.)5.00 'SEISMIC FEE CONS'T'RUCT ION LENDING AGENCY EXHAUST HOOD (WITH DUCT) 2.00 - MICROFILM I hereby affirm that there is s construction lending agency far the performance of the work for which this permit is issued (Sec. 3097, CN.C.). HEATING UNIT (TO 100,000 B.T.U.) 4.00 HEATING UNIT (OVER 100,000 B.T.U.)7.50 Lender's Name ELECTRIC Lender's Address I certity that 1 have read tholipphcation andsWte that the above information is correct. I agree 10 comply with all city and county „( 0�dirtir.ces and stale laws relating to building cn,oructon, and . hnreby mill orlie representatives of this city,.t0 ewer upon the VENTILATION FAN (SINGLE) 3.00 PLUMBING Q G� BOILER-COMP(3 H.P. or 100,000 B.T.U.) 4.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL _ above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments. costs and expenses which nluy in joy way accrue against said City in consequence of the grunt' of t i ennil. MISC.- ' REFER TO ORD. CONST. TAX PERMIT ISSUANCE 3.00 MECH. CONT. LIQ N0. - MECH. roTAL TOTAL S a arc of Ap 'aril/Con 'lar )ale A OFFICE COPY t