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5944APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION &PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 5944 a°ILoINo 87 A -r*? Woob ADDRESS OWNER'S NAME YOM'fV tiOZF IL OTV. ELECTRIC PERMIT cPLAN CHECK NVALIDATION Af-��PHONE 6CONTRACTOR'S vNAMI)ijr OUTLETS-SWITCHES-RECEP 5.00/1.00 ca uc. NO. y DATE OF APPLICATION LIGHTING FIXTURES 5.00/1.00 ADDRUE caoR' ADDRESS PHONE APPLIANCES 4.00 v PANELS 5.00 ARCHITECT / C..n I.1•:k fY}�%1 OR f/ T ENGINEER r,>" IronfGR uc. No. SIGNS 6.00 PLAN CHECK FEE P.C. NO. PLAN SIGNS TRANS. 3.00 ARO,. OR ENG. ADDRESS �P6 11_ Sr g7 �LEBL1�f�' 2tP (y SPECIALCIRCUIT v 5.00 • PERMIT VALIDATION �� EMP. METER OR POLE INS. 15.00 APPLICANTS ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 /Y/,J ' LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (cnnunencing with Section 7000) of Division 3 of the Business and Professions Codc antl my license is in full force and effect. License Class Lic. Nun, ber ISSUANCE DATE BLDG. ELECT. PLG. MECH. UamContractar rBUILDING PERMIT OWNER -BUILDER DECLARATION /< I hereby Ellin that I un, osempt from the Contmmors License Law for to following reason.(Sec. 703 1.5, flushessand Professions Code: Any city or county which requiresa permil loconstruct,aller. improve, demolish. ar repair any struelure, prior to its issuance, also requires the applicant fur such permit 10 Nle a signed statement that Ile is licensed pursuant to the provisions of the Contrmtor's License Law (Chapter 9(cnmmencingwith Sectino 70000of Division 3of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Sect ion 7031.5 !I INFORMATION MISC. - REFER TO ORD PERMIT ISSUANCE 6.00 VALUATION $/FT. ELEC. CONTR. LIC. NO. ELEC. TOTAL 3' � PERMIT TO / q d CITY. PLUMBING PERMIT FEE I_ STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant to acivil penalty of not more than five hundred dollars 155001.1: ALTER -DRAIN & VENT -WATER (EA.) 4.00 ❑ I, as owner of the property, or my employees with wages us their sole compensation, will do the work, and the st rocture is not BACK FLOW PROTECT. DEVICE 2.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND.4.0 0 intended or offered for sale (Sec 7044, Business and Professions Code: The Contractor's License Law dos not apply to an owner of ro property who builds or improves thereon, and who does such work I I in,sellor through his own employees, provided that such improve. k'h�Rrnents are not intended or offered for sale. If, however, the building $0. FT. FLOOR AREA TOTAL ACREAGE FIXTURES - PER TRAP 4.0 - f GAS - EA. SYSTEM -1INC. 4 OUTLETS 4.00 Ile I, 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.). ❑ I, as owner of the property, am exclusively contracting with I GAS' EA. SYSTEM - OV ER 4 (EA.) .1.00 BUILDING USE RES IND CON PB Omer ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 20.00 licensed contractors to emstruct the project (Sec. 7044, Business and profession, Code: *1 he Can tractors License Law does not apply In an owner of property who builds or improves thereon. and who LAWN SPRINKLERS - 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. LAWN SPRINKLERS - OVER 5 (EA.) 1.00 contracts for such projects with a contractors) licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT NO. PARCEL NO. ❑ I am exeRmt under Sec. , [I &P C. tin this reason WATER HEATER W/VENT 4.00 Owner Date WATER SYSTEM 4.00 ACC.DATE ACC. FILE NO, WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 I hereby ;dorm that 1 hove a certificate of cumwill to ,H insure, or a certificate of Workers' Compensation Insurance, Or a certified ZONING ENG. SITE NO. copy Ther- fISee 3 00, Lah.C.). Policy N -on,Pany / ElCertified copy is hereby famished. ❑ Certit� y�d� p s ,Ided Th II • city inspection division. Applicant-ll//��-�51CG1W�� (�. FIRE SPRINK YE] N❑ ENERGY T 24 Y❑ NEIN MISC.- REFER TO ORD. CE;R'I'I FICAT17 OF EXEMPTION FROM WORK ERS' PERMIT ISSUANCE 6.00 �" rp FLOODZONE A.L.U.C. PLG. CONTR. LIC. NO. PLG TOTAL �` COMPENSATION INSURANCE: ('Phis section need not he completed if file Punnit is for one Y ❑ N❑ v ❑ N❑ CITY. `MECHANICAL PERMIT FEE -- FEE SUMMARY hundred dollars (S 100) or Icss.l I certify that in the performance of the work for which this per. mit is issued, 1 shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Dale Applies,,( BUILDING e2 5 G O ALTER OR ADD TO MECH. 4.00 N(1'] WE'f0 AI'I'LICAN'1': It, after making this Certificate of Bx- APPLIANCE 4.00 PLAN CHECK eruption, 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 10SMC.F.M.) 3.00 AIR HANDLING UNIT (OVER 10=C.F.M.) 5.00 SEISMIC FEE 77 J �� CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency Or EXHAUST HOOD (WITH DUCT) 2.00 the performance of the work for which this permit is issued (Sec. 3097, Civ.C.). MICROFILM HEATING UNITITO 100,000 B.T.U.) 4.00 Lender's Name HEATING UNIT (OV ER 100,000 B.T.U.17.50 ELECTRIC / Lenders Address I certify Ilia t I have read this application and state that the above information is correct. I agree to comply with all city and county Mances and state laws relating to building construction, and .elsy authorise representatives of this city to enter upon the above-Inenh... ell property for inspection Im,poscs, VENTILATION FAN (SINGLE) 3.00 - PLUMBING pY BOILER -DOW (3 H.P. or 100,000 B.T.U.) 4.00 BOILER -COMP lover tDO,00D BTU) SEE FEE SCH. MECHANICAL / (P MISC. - `\ REFER TO ORD - (we) agree to save, indemnify and keep harmless the City of Cupertino against liabilities;judgments, costsand expenses which .may in any way accrue against said City in consequence of the CONST. TAX PERMIT ISSUANCE 3.00 -- grantingofthispemft. GtllrA/S egkr �j F.f //a hoET MECH. CONT. LIC. NO, MECH. TorAL o =0 TOTAL 3/r� FS SignaW"�pplicant Detractor Dui INSPECTOR COPY