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8172 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BILI LDI NG PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT ADDRESS BUILDING -ELECTRICAL-PLUMBING-MECHANICAL ' 7 7Q / 8172 O S PLAN CHECK VALID TION NAMEL1-�j✓meB14 !`Z. OTY. ELECTRIC PERMIT FEE • �G� -f PHO 'V 37s� co o ' OUTLETS-SWITCHES 10-00/1.00 �j NAMEE LIC.ND, Q LIGHTING FIXTURES 10.00/1.00 Ch_ CONTRA row's ADDRESS APPLIANCES-RESIDENTIAL 4.00 LU /p A� ✓I ( PANELS 10.00 - DATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P,C.NO. OR ENG INEE LIC.No. SIGNS TRANS. 3.00 ADDR.O Ery PERMIT VALIDATION ;nr el ADDRESS 5 ^}Q SPECIAL CIRCUIT 5.00 �c�nr^-�7zIP EMP..METER OR POLE INS. 20.00 A ADDRESS DDRESS r$ MOTORS n SEE FEE SCH. W SERVICE CHANGE 20.00 `/YG�� woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 a u w I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE H (commencing with$edion 70001 of Division 3 of the Business and BL G ELECT. PLG. MECH, F 1 12 D i I".1c"ioms Code and my license is in full force and effecL a, o m - License Class Lic.Number ©\ �� o w r Dote Contrac tor Q y f J rlj BUILDING PERMIT rc it w a OWNER-BUILDER DECLA RA'f rl�' o a " MISC.- REFER TO ORD INFORMATION w3 a H I hereby:dlinn Ihatl avt ex em pl from the Con l rucl ori LIcense HaOJ La w for t h e I.Ilowi ng rcasou.ISec.7031.5,B itsi n cis an d Profession VALUATION $/f T. s , (� Code:Any city or county which requires a permit to construct,alter, ISSUANCE 10,__00ulte Q Q¢ 2 Improve,demolish or repair any structure,prior to Its issuance,also ELEC.CONTE. LIC.NO. ELEC A . (r to a mo requires the applicant for such permit to file a signed statement that TOTAL/ PERMIT TO .w m he is licensed pursuant to the provisions of the Contr actor s License `r 1 rzi• La-(Chapter 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE ¢ o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. a _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN VENT-WATER (EA.) 5.00 of not more than five hundred dollars(SS00r): .21 ❑ I,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,AREA,GOND. 5.00 D / 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 „�'` 50.FT.FLOOR AREA TOTAL ACREAGE • himself re through his own employees,provided that such im building l/- inerts are not intended or offered for sale If,however,the hwlding GAS-EA.SYSTEM-1 INCA OUTLETS 6:00 a �y 7 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 builder will have the burden of proving that he did not build or im- BUILDING USE prove tin purpose ofsale.l. INDUSTRIAL WASTE INTER3000 E IND .CDN PB Dme, . . ❑ I,as owner o1 the property,ant exclusively contracting with ❑ ❑ ❑ ❑ licensed contractors in construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Code:Tire Contractor's License Law does 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 a commoonlx)licensed pursuantU'to SEWER-SANITARY STORM EA.200ft/1-0:00 11 Q the Contractor's License Law_ l/ TRACT NO. PARCEL NO. O l am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00 ,S(!Jp 7l0 reason Owner Date WATER SYSTEM 5.00it Ur/ ACC.DATE ACC.FILE NO. WORK ERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent to self-insure, ZONING or a certificate of Workers Compensation Insurance,or a certified ENG.SITE NO. copy thereof(Sec.3800,Lab.0 Policy No. Company�rM,,,�� 4r,tr f" O ❑ Ccrtilicd copy is hereby furnished , FIRE SPRINK ENERGY T 24 Z Z O Ce ifild copy is filed with the city insp•'lio diwsii. O Al"licatnl s�ues�4., � MISC: REFER TO ORD. Y ❑ N❑ Y ❑ N❑ CC T) CER nizicATIi PE(6M1'fIONI ROM -_ 44- PERMIRISSUANCE 10.00 � FLOOD ZONE aL.0 c. ii W > COMPENSATION IN—RA NCE PLG.CONTR. s\ LIC.NO. PLG C p.p ❑ ❑ ❑ ❑. CL O (This section need not be completed if the permit is for one TOTAL v N Y N ::) Z hundred d.11...($100)or IessJ U O 1 certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY U_ F- mit is issued,I shall not employ any person in any manner so as to OW become subject to the Workers Compensalion Laws of California. // Ct. Dale Apphnant ALTER OR ADD TO MECH. 5.00 BUILDING >_ to NOTICE'f0 APPLICANT: If.after making this Certificate of Etc- Z emption,you should become subject to the Workers4. 11z 'Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE /� '�U 1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DWC.F.M.) 6.00 SEISMIC FEE Cj I hereby affirm that there is, construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 the perlixnunce of the work for which this permit is iss'u ed(Sec. MICROFILM 3097,CR,.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00 UJ Lender's dIp 6 N4✓ HEATING UNIT(OVER 100,000B.T.U.)9.50 Lender's Address�6`-E3 Inc ,1j��,�G>;- fh ELECTRIC A _ 1 certify that I have read this op,licution and state that One above VENTILATION FAN (SINGLE) 4.00 [N information is correct. I agree to comply with uII city and county PLUMBING ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 hereby autlmrire representatives of this city to enter ninon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL a �` above mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. / Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 iW CONST.TAX may in any way accrue against said City in consequence of[he CJ guiding of this permit MECH.CONT. LIC.NO. MECH. ^r TOTAL o-o TOTAL ( �/ Sga vac ofApplicand7l7cantra r Uae /x1 INSPECTOR COPY