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8229 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 'BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER BDILO,NG APPLICATION & PERMIT /� ADDRESS )9 BUILDING—ELECTRICAL—PLUMBING—MECHANICAL G NER'5 !I - PLAN CHECK VALIDATION "AmE• /f'/ A/0 QTY. ELECTRIC PERMIT FEE 4✓l Jam./ �/ (1 PHONE Q NAME CTOR'S NAmE / OUTLETS-SWITCHES-RECEP 10.00/1.00 LIC.NO. LIGHTING FIXTURES 10.00/1.00 CTRAAcm'OR's ADDRESS PPLIANCES-RESIDENTIAL 4.00 PHONE PANELS 10.00 DATE OF APPLICATION ARCHITECT PLAN CHECK FEE P.C.NO. OR PANELS (OVER 200 AMP) 20.00 1 ENGINEER ' uc.u0. SIGNS TRANS. 3.00 t' coo ESS ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP fTEMP.METER OR POLE INS. 20.00 APPLICANT MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 woo LICENSED CONT RACTORS DECLA RATION TEMP.POLE 30.00 ¢ u v I hereby affirm Ihat I :un licensed under provisions of Chapter 9 ISSUANCE DATE z w (commencing with Section 7000)of Division 3 of the Business and ¢ vAi' BLDG. ELECT. PLG. MECH. r y z Professions Code,add my license is in full lone and effect ❑ © � ;q 2 O m - License Class Lic.Number u H I-w DmC Contractor BUILDING PERMIT K ¢ a OWNIER BUILDER DECLARATION A o a uINFORMATION X 3 LL N I hereby affirm that I am exempt from the Contractor's License JMISC.— REFER TO ORD vgLugTION S/FT. r LL O J Law for the following reason.(Sec.7031.5,Business and Professmus PERMIT ISSUANCE G iDAO ' Code:Any city or county which requires u permit In construct,idler. n rove,demolish,ur re m i an structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ¢ ¢ a O ° p lar Y ,LEC. Ea O R requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO n X m" he is licensed pursuant to the provisions of the Contractor's License F z r Law(Chapter 9(commencing with Section 7000)of Division 3 of the P�,gE p_�LCG 5 i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢ I- the basis for the alleged exemption.Any violation of Section 7031.5, 1 STORIES TYPE CONSTR. w. 5,; by any applicant for a permit subjects the applicant to a civil penalty b ALTER-DRAIN 0 of not one than five hundred dollars(S500).0 I J,0 ❑ I,asowner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE '4.00 OCCGROUP RESUNITS their sole compensation,will do the work,and the structure is not . RES._UNITS intended or uttered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:'Fite Ccut actor's License Law does not apply to un owner of property who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE himself re through his own employees, le.If,provided that such improve. mends are not ugh his or offered for sale.R,ed thathowever,s the building GAS-EA.SYSTEM-1 INCA OUTLETS 6.00 or improvement is sold within one year of completion. . . .00 the owner- GAS-EASYSTEM-OVER 4 (EA) 2 builder will have the burden of proving that he did not build or im- BUILDING USE prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RES IND CON PB Other ❑ I,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 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 wi m u comraotorfs)licensed Pursuant it) SEWER-SANITARY-STORM EA.200ft/10.00 tlm Contractors License L' TRACT NO. PARCEL NO. ❑ I am exempt to Sec. B.&P.C.for tis WATER HEATER W/VENT 6.00 Owne Dare WATER SYSTEM 5.00 ��. ACC.OATE ACC.FILE NO. WORK F-RS'COMP1ENSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified copy lhereof(See.3800,Lab.C.). Policy No- Company O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24 z Z ❑ Certified copy is tiled with the city inspection division. MISC.- REFER TO ORD. O Applicant Y❑ N❑ V ❑ N❑ CC w CERT1171CA'I'I:OF EXEMPTION FRONI WORKERS PERMIT ISSUANCE - .10.00 — FLOOD ZONE A.L.U.C. LU .COAIPENSATION INSURANCE PLG.CONTR. LIC.NO. ^PLG. (L Z (This section need not be completed if the permit is for one TOTAL /0 ' Y❑ N F] Y El [:1N hundred dollars($100)or less.) U O I certify that in the parfoa rmnce of the work 1'o,which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY EL k- Emil is issued,I shall not employ any persoa H in airy manner so as N' Ow becom esubjcct to tire m e Workers'Copen [.;I., m sation ws of Culifoia. a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } N NOTICE TO APPLICANT: If,after making this Certificate of Ex- F-• ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must Rortbwitl comply with FEE U 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 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 tic work for which this permit is issued(Sec. MICROFILM 3097,Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Nome Lender's AddreHEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC /I ss I Certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00 information is correct. I agree to Comply with all city and county PLUMBING (f ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 Hereby authorize representatives of this city to enter upon the BOILER-COMP IOvar 100.000 BTU)SEE FEE SCH. MECHANICAL above mentioned property f inspecior purposes. (We) agree to save n emnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against ilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX may in any yo %i, uc Iagainst said City in-mn cquence of the gr min 11 Penn it CECH.CONT. LIC.NO. MECH, / TOTAL TOTAL d' — ik pe c, pplicant/Contract r Date INSPECTOR COPY II