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C8273 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER BORGING APPLICATION & PERMIT �� �L ADDRESS / L J BUILDING -ELECTRICAL-PLUMBING-MECHANICAL _,L_ OW ER'S VALIDATION NAME QTY. ELECTRIC PERMIT C _ FEE NAMEA TORS OUTLETS-SWITCHES-RECEP 10.00/1.00 JUN 5 1985 LIC.NO. LIGHTING FIXTURES 10.00/1.00 CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 ADDRESS City of Cupertino / PHONE PANELS 10,00 DATE OF APPLICATION OR RCMITECT PANELS (OVER 200 AMP) 20,00 1' PLAN CHECK FEE P.C.NO. It ENGINEER LIC.NO. SIGNS TRANS. 3.00 ARCH.OR ENG. PERMIT VALIDATION ADDRESS SPECIALCIRCUIT 5.00 ZIP TEMP,METER OR POLE INS. 20.00 APPLICANTS MOTORS SEE FEE SCH. ADDRESS lJ SERVICE CHANGE 20.00 o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 M mo u I hereby affirm that 1 nm licensed under provisions of Chapter 9 ISSUANCE DATE Icon rn'tte ng with Section 7000)of Division 3 Of the Business and a w BLDG. ELECT. PLG. MECH. z I'rnl essions Code,and my license is in full force and eRecL z o w- License Class Lic.Number Dale Contractor ¢ m E BUILDING PERMIT ¢ ¢ OWNER-BUILDER DECLARATION oto u INFORMATION wI hereby affirm that I am exempt from the Contracmr's License MISC.- REFER TO ORD LL o a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION 3/FT. � - 0 Code:.Any city orcounty which requires a nit toconstruct.alteq per: ELEC. UC.NO. '� 000, -Q ¢ a improve,demolish,or repair any structure,prior to its issuance,alw ELEC. i` wO u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO m w he is licensed pursuant t°the provisions of the Contractor's License Hz > Law(Chapter 9(commencing with Sed ion 7000)of Division 3 ofthe Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE 1,h 11411 it =m the basis for the alleged exemption.Any violation of Section 7031.5 5 T CONSTR. ' ..Si 3 by any applicant fora permit subjects the applicant toacivilpenalty ALTER-DRAIN& VENT-WATER (EA.) 5,00 t of not more than five hundred dollars(5500).1: ❑ 1,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 the work,and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 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 re through his own employers,provided that such improve- are intended or offered,a,h,c,sale.if,however,the building GAS-EA.SVSTEM-1 INC.4OUTLETS 6.00 or improvement is sold within one year of contplelion, the owner - . . .00- GAS EASYSTEM-OVER 4(Eq) 2 builder will have tire' burden of proving that lac did not build or im- BUILDIN USE prove 1,as owner of sale.(. INDUSTRIAL WASTE INTER. 30.00 _ ❑RES I❑ C ,❑ Other❑ b7�L as owner m the property,he exclusively contracting with I' a J contractors : construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSOR PARCEL N0. and Professions Cole:The Contractors improv Law does not apply to tr owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 the Contractor's License Law. TRACT NO. PARCEL NO. ❑ l am exempt under Sec. ,R.&P.C.for this WATER HEATER W/VENT 6.00 wn Owner Uutu ?/.��/ - WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKE:RS'COMPENSAT10N DICLARAT ION/'`_!�� WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of-consent to sel Ginsure, ZONING ENG.SITE N0. or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800.Lab.C.). Policy No- Company O D Certified copy is hereby furnished, FIRE SPRINK ENERGY T 24 Z Z ❑ Certified copy is fled with the city inspection division. O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N[ cc: CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE _ 10.00 FLOOD ZONE A.L.U.C. CL LU > COMI'IiNSA'1'ION INSURANCE PLG.CONTR. 'LIC.NO. - PLG. ❑ N❑ ❑ ❑ o 1'I'his section need not be completed if the permit is for one ` 1 TOTA V V N Z) Z hundred dollars IS 100)or less.) U O 1 certify that in the performance of the work for which this per OTY MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued,1 shall not employ any person in any manner so as to �,`` V become subject to the Workers'Compensation La o(Calilornia. n Date Applicant I _ ALTER OR ADD TO MECH. 5.00 BUILDING I - } 0NOTICE TO APPLICANT: If,after making this Certificate of Exif - �� Z emption,you should become subject to the WorkeTs Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Lubar Code, you must forthwith coply with U such provisions or this permit shall he deeaned revoked.o AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE CONSTRUCT[ON LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE 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 MICROFILM 3097.Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address HEATING UNIT(OV ER 100,000 B.T.U.)9.50 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 andcounty PLUMBING ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,0006.T.U.) 6.00 hereby authorize representatives of this city to enter upon lira BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property for inspection purpoxs. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which CONST.TAX may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 grantingofthisp ran. MECH.CONT, LIC.NO. MECH. 1 �� TOTAL TOTAL " re o)"Ap Ilc;urt/ ntractnr �atT > �J INSPECTOR COPY )