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8428 (3) APPLICANT TO FILL IN INFORMATION WITHIN,RED LINES - USE BALL POINT PEN ONLY `�yGa • BUILDING PROJECT lDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER aua0mc ADDRESS BUILDING-ELECTRICAL-PLUMBING -MECHANICAL8428 OWNERPLAN CHECK VALIDATION NAME OTY. ELECTRIC PERMIT FEE '- • PHONE NnAIE Ac sN- a UTLETS-SWITCHES-RECEP 10.00/1100 uc.ND. LIGHTING FIXTURES > 1000/1.00 < s APPLIANCES ADDRESS 0 vnOrvE _ PANELS 10.00 DATE OF APPLICATION T A TO ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. OR ENGINEER - LIC.No. SIGNI TRANS. 3.00 ARCH,OR ENG. PERMIT VALIDATION ADDRESS SPECIAL CIRCUIT-::''._.-.� zIP JTENPFMETER;OR POLE INS. 20.00 APPLICANTSMOTORS SEE FEE SCH. S ADDRESS ss SERVICE CHANGE Q,� / . ar 0 2 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ��0t a v1 hereby affirm that 1 any licensed ruder provisions of Chapter 9 ISSUANCE DATE H (commencing with )of othe Business an Qz n ( iih Section 7000f Di3fhBid 130� 544 BLDG. ELECT. I PLG. MECH. F w i Professions Code,anti my license is in full force and effect. Ar_fl,,s - ❑ © ❑ ❑ z o w - License Class EIli Li,.Ntructorumber o y F ° Dat- On /L{G G �hy/ p/-!.v/_�S G✓� (` a sa E Sw I Ji( BUILDING PERMIT c w a OWNER-BUILDER DECLARATION INFORMATION Xo u I I herebyaffirm that I am exenm rot from the Contractors License MISC.- REFER TO ORD 3 0 w 1 VALUATION §/FT. .. 0Q Lew for the following reason.(See.703"5.Bunt tocodProfessions PERMIT ISSUANCE Hwy improe,derrAny yar coolly ntywhieh rcquimsap)FiOT0 condom",also 2 E ey SO improve,it,applicant or rope it:cry stn¢tore,prior to its issuance,also ELEC.GONTR. LIC.NO. TOTAL is - o ¢ ..quires the dp uisua t To the pemsit to file a signed statement that A. I _ - TOTAL Q� PERMIT'TO E m U. he is licensed pursuant m the provisions of the Contractor's License � zQ Law(Chapter'I fconunumeingwilh Section 7000)of Divis'ion3 oftlic 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE .rely o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. by any applicant fore punkt Subjects the applicant too civil penally ofnot more than five hundred dollars(S500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00 ❑'I,as owner ol'tire property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG.GROUP RES.UNITS their sole compensation,will do the work,and the structures not intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 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 TOTALACREAGE himself or through his own employees.Provided that such imP.ove- mentsarenotintendedorofferedforsale.If,however,0m building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 or improvement is sold within one year of completion, the owner- GAS EASYSTEM-OVER 4 IEA ) 200 builder will have the burden of proving thin h - . . . e did not build or im- BUILDING USE prove for purpose of sale). RES IND CON PB Omer ❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑ licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 - ASSESSORS PARCEL NO. and Professions Code:The Contreewe'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 contracto-6)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00 the Contractor's License Law. TRACT NO. PARCEL NO. ❑ Iamexemptunder Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO. WORK ERS'COAIPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate ofc.nsent to self-insmC ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO. copy thereof(Sec.3800,Lab.C.). ' Policy No. COtllPany d- 0 ❑ Certified copy is hereby f rmA� �[' ( Q/}' FIRE SPRINK ENERGY T24 Z z Certified c s IileJ wish Ihcwi' I pecM1uif A�sIy. O Alf g}I .m, MISC.- REFER TO ORD. Y❑ N❑ - Y ❑ N❑ I-- w PERMIT ISSUANCE 10.00 CC - f-ER'I'I PICCOMPE Ii%Eh1 N ION PROM WORKERS' FLOOD ZONE A.LU.C. W > COh1PIiNSAT'IOINSURANCE PLG.CONTR. LIC.NO. PLG. � 0 This section need not be completed if the permit is I'or ane TOTAL Y❑ N❑ Y ❑ N❑ hundred dollars IS 100)or less.) U O 1 Certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued,1 ,droll non ctrl Ploy any PC...an in any mann..so as to U become subject to the Workers'Conipef,at ion Laws of California. O a °ant Datc Appli ALTER OR ADD TO MECH. 5.00 BUILDING } W NONCE '10 APPLICANT': 11,after making this Certificate of lix- :F 2 enation,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, You must lorthwith comply with - FEE U such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 CONSTRUC'T'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency hn EXHAUST HOOD(WITH DUCT) 5.00 the performance Of tlm work for which this permit is issued(Sec MICROFILM 3097,CieCA - HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's NameHEATING UNIT 100,000 B.T.U.)9.50 ELECTRIC Lenders Address f _ I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 • inm tbration is correct. 1 agree 10 Comply with all city and county PLUMBING BOILER-COMPI3 H.P.or 100,000 B.T.U.) 6.00 odinences and state laws relating In building construction, and hereby aulhorim representatives of this city to actsr upon the BOILER-COMP (Over 100,000BTU)SEE FEE SCH. MECHANICAL 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 expenseswhich CONST.TAX may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 gmntingofthis permit. MECH.CONT. LIC.NO, MECH. TOTAL TOTAL u e o tic m Contractor a INSPECTOR COPY