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9196O Z z I... O CC T UJ _ CL D 7)z UO LL r- Oa } SO F � Al APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION , APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 9196 IG A DDN ooRESs 0 f, e kip, OWNER'S NAME li P .- _j_ _ j/ OTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION TV PHONE S COONTERACTORs r Cc npQ, CLIC NO I ZD UTLETS- SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 CONTRACTOR'S CONTRACTORS APPLIANCES - RESIDENTIAL 4.00 PANELS 10.00 " rl(c LONE C DATE OF APPLICATION nA ARCHITECT h L�lf I�J OR LEI ENGINEER LIC. NO. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ADDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION EMP. METER OR POLE INS. 20.00 zlv S APPLICANTS ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and s3ppy license is in lull force and effec . License Class l���L � Lic. Number ISSUANCE DATE BLDG. ELECT. ❑ ❑ PLG. MECH. � ❑ Dump �7 '1 �S'•. i Contractor BUILDING PERMIT INFORMATION OWNER -BUILDER DECLA ATION I hereby affirm that 1 am exempt from the Contractor's License Law for the following mason. (Sec. 7031.5, Businessand Professions on 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 statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000)of Division 3 of the Business and Professions Code) or that he is exempt therefrom and MISC.- REFER TO OR VALU ATION E/FT. PERMIT ISSUANCE 10.00 ELEC. CONTR. LIC. NO. ELEC. TOTAL PERMIT TO Al QTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (S500)J: gLTER-DRAIN-WATER (EA.) 5.00 Cl 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not BACK FLOW PROTECT, DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00 intended or offered for sale (See. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- ments are not intended or offered for sale. If, however, the building FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE GAS - EA. SYSTEM - 1 INC. 4 OUTLETS 6.00 or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or im- prove for purpose of sale.).INDUSTRIAL ❑ I, as owner of the property, mexclusively contracting with m GAS - EA. SYSTEM - OVER 4 1 EA.) 2.00 RES IND -CON PB omen ❑ ❑ ❑ ❑ ❑ WASTE INTER. 30.00 licensed contractors to construct the project (Sea 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. contracts for such projects with a contractons) licensed pursuant to the Contractors License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑ Iamexctnptonder Sec. ,B.&P.C.for itis reason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC.OATE. ACC. FILE NO, WATER TREATING EQUIP. 5.00 WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to sell'-insum' or a certificate of Workers Compensation Insurance, or a certified ZONING ENG. SITE N0. 9 copy thereof(See. 3900, Lab.C.y ,Policy No.Company - I , lAl' Or 1110 �7 A FIRE SPRINK Y ❑ N❑ ENERGY T-24 Y ❑ N❑ .M ❑ Certified copy is hereby uurnls ed. ❑ Certified copy is filed with the city inspection division. r Applicant,�j MISC. - REFER TO ORD. [7 p ZCIIRTI CCATEU I:X ih X10 IrR MWO711` PERMIT ISSUANCE 10.00 FLOODZONE A.LU.C. PLG. CONTH. LIC. NO. PLC TOTAL COMPENSATION INSURANCE (This section need not be completed if the permit is for one Y N ❑ ❑ Y N ❑ ❑ hundred do1lsrs(SI00) or less.) 1 certify that in the performance of the work for which this per. mit is issued, I shall not employ any person in any manner so as to DTV. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of Califorrim. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Ex ALTER OR ADD TO MECH. 5.00 TS n0 APPLIANCE 5.00 PLAN CHECK emptier, you should become Subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked FEE AIR HANDLING UNIT (TO 10=11F.M.) 4.00 AIR HANDLING UNIT (OVER 10=11C.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY 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. 3097, Civ.C.), MICROFILM I HEATING UNIT (TO 100,000 B.T.U.) 6.00 HEATING UNIT (OVER 100,000 B.T.U.) 9.50 ELECTRIC Lender's Name Name Lender's ss I certify that l 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 ordinances and state laws relating to building construction, and PLUMBING BOILER-COMP(3 H.P.or100,000B.T.U.) 6.00 BOILER-OOMP (Over 100,000 BTU) SEE FEE SCH, MECHANICAL hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. MISC. - REFER TO ORD. CONST. TAX (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which' may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 �Or OD MECH. CONT. LIC. NO. MECH. TOTAL d.� TOTAL gr ling Of this p tm' ...'�^J,- Ignatare of p cant/Contractor Dale OFFICE COPY