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8365 APPLICANT TO FILL-IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT �� ADDREE" 6/6 �% /�A/D�� L__ VVV /.!�/ -fI BUILDING-ELECTRICAL-PLUMBING -MECHANICAL OwNt / NAMEfl'S PLAN CNEC K VALI DAT ION �- "AME OTV. ELECTRIC PERMIT FEE v"DrvE 1 •� NAME AC Rs 33 UTLETS-SWITCHES-RECEP 10,90/1.00 STe%Nci✓ Y _ uc.No. LIGHTING FIXTURES 101]0/1.00 C0617RAcTotps [a PP LI ANCES-RESIDENTIAL 4.00 ADDRESS nO /JJX ��Opl Y �7 NE PANELS lam DATE OF APPLICATION OORRCRITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0. ENGINEER uc.rvo. SIGNS TRANS. 3.00 ARCH'Ess ENG. SPECIAL CIRCUIT $,QQ PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 APPLI DDHESCASTS ADRMOTORS - SEE FEE SCH. J SERVICECHANGE 20.00 11 o o LICENSED CONTRACTORS DECLARA'T'ION TEMP.POLE 1 30.00 < U u I hereby affirm that I am licensed under provisions of Chapter 9 a "I ISSUANCE DATE I w< wz Professions Code,and my license is in full force and effect.(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. O Licen Z r m t ©` ©_ so se Class Li C.Number, o w r bate Contractor a Y s BUILDING PERMIT IC4 OWNER-BUILDER DECLARATION Ro n to INFORMATION X ; LL y 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION SIFT. F LL O J Law for the following reason.(Secy 7031.5,Business unJ Professions PERMIT ISSUANCE 1�nn Code:Any city or county whichrequiresapermitnoconstruct,altcq / TT QQ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. I] a Z requires the applicant for such permit to file a signed statement that TOTAL 3 - PERMIT TO w $m he is licensed pursuant to the provisions of the Contractor's License 4 � i N� I- za Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe S/O�. �1�Oi T/ 2 4 O Business and Professions Cods)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE GD N y-m the basis for the alleged exemption.Any violation of Section 7031,5 STORIES' TYPE CONSTR. n ; _ by any applicant l'or a permit subjects the applicant ton civil penalty ALTER-DRAIN -WATER IEA) of not more than five hundred dollars(S500U . : 5'DO ❑ 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 cur offered for sale (Sec 7044, Rosiness and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:'rhe 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.FLOORAREA TOTAL ACREAGE himself or through his own employees,provided that such improve- normsarenotintendedorofferedl'or sale.If,however,the building / GAS-EA.SYSTEM-1 INC.4 OUTLETS 0 H improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA.) 200 builder will have life burden of proving nha('lic did not build or ice - . - . . - BUILDING USE prove for purpose ofsele.). INDUSTRIAL WASTE INTER. 3000 RES IND CON PS Omer . ❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ 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 Com actor's License Law does not apply to an owner of property who builds or Improves t:erre0u,and who LAWN SPRINKLERS-OVER 5(EA.) 1.0 111 contracts for such projects with a contractor(s)licensed pursuant to SEWEpp SANITARY-STORM EA.200ft/10.00 lbs Contractors License Law. •t' TRACT NO. PARCEL NO. ❑ lam exempt under Sec.-.BAPC.for this WATER HEATER W/VENT 6.00 leas." Owner Dam WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that 1 have a certificate of consent to self-insure. or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO. copy lhereol'(See 3808,Lab.C.). Policy No. Company O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T-24 I Z Z ❑ Certified copy is filed with the cit- inspection division. O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ Is CC rn -ON PERMIT ISSUANCE 1 W > CERTII'ICCOMPliNSATONIINSURANCE ROM ORKI RS PLG.CONTR. J LIC.NO. PLG FLOOD ZONE A.L.U.C. h-2 O U Y❑ N❑ /Y❑ N❑ � Z hundred section need not he completed if the permit is for one TOTAL JJ hundred dollars(5100)or leer,) 0 O 1 certify than in the perhouren c of the work for wind'this par- OTV.. '4 MECHANICAL PERMIT FEE FEE SUMMARY (y f mit is issued,I shall not employ any person in any Inammr so as to Ow become sobject 1.the Workers'Gym en^axon Laws of 9y j(pL2ia. a Dam'y'ib'SjS-Applteanl fS,. ��� - ALTER OR ADD TO MECH. 5.00 BUILDING } m A NOTICE; API'I,ICAN'I': Ih ufler making this Certificate of Ex- N empnion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must 10TIllWdll Comply with FEE CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 CONSTRUCI ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000GEM.) 6.00 SEISMIC FEE 3 -zL I hereby affirm that Imre 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.). HEATING UNIT(TO 100,000 B.T.U.) B:OB -- Lender's Name HEATING UNIT IOV ER 100,000 B.T.U.)9.50 ELECTRIC 3y Looter's Address certify the I have rand this application and state the the above VENTILATION FAN (SINGLE) 4A0. 7 information n colot, la agree ti comply with all city and county BOILER-COMP(3H.P,oT100,000B.T.U.) 6.00 PLUMBING 3 / ordinances and state laws relating to building construction, un, hereby authorize representatives of this city to eater upon the BOILER-COMP (Over,00,000 BTUI SEE FEE SCH. MECHANICAL. /O (}S1 above-mentioned property for inspection purposes. I (We) agree no save, indemnify and keep hioness the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs mW expenses which CONST.TAX may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 -- gra�ntingofthis•-permlt. (.� / MECH.CONT. LIC.NO. MECH, .Tc J��Z�7- TOTAL /o ` TOTAL 3'ScCl - Slgnaturc of want Contr_7 Du(L INSPECTOR COPY ` I