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09867APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTIFICATI ON. APPLICATION &PERMIT - BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMITNUMBER 09867 r� I BUILDING ADDRESS OWNER'S "AME Dad/e�! t`s�� PH TY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION CONTRACTORS q NAME OUTLETS -SWITCHES-RECEP 10.00/1,00 0 Ci!-•��G��I3 uc, NO. LIGHTING FIXTURES 10.00/1.00 DATE OF APPLICATION ONTRACTORS AO RES {�$/�,/�`zN�E eE Pf GV NES 40 APPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 ORRCHITECT PANELS(OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. ENGINEER LIC NO. SIGNS TRANS. 3.00 nooeess E"G' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION EMP. METER OR POLE INS. 20.00 ZIP ADDRESS rs ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 ' \ �� ��yz/ QQSS LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 S 's I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Codq license is in full fort ,,� License Clas Lic. Number. ,icim Comractor - OWNERtBUILDER DHCLARATION I here the affirm that (am exempt from theContractor'srs License Law for the following reason (Sec. 7031.5, Businessand Professions Code: Anycityorcounty which requires a permit to construct, alter, IS ANCE DATE sp C�BLDG. - ` �VSo • tJ �` EL CT. PLG. MECH. EJDale BUIL NG PERMIT INFORMATION MISC. - REFER TO ORD PERMIT ISSUANCE 10.00 VALUATION $/FT. ELEC. CONTR. LIC. NO. E'EC. Jyyy����• TOTAL !YO O ` Improve, demolish, or repair any Structure, prior to Its bourn", also requires the applicant for such permit to file a Signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the PERMIT TO r Business and Professions Code) or that he isexempt therefrom and OTY. PLUMBING PERMIT FEE the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant o acivil penalty of not more than five hundred dollars (55001.) STORIES TYPE CONSTR. ALTER -DRAIN -WATER IEA.) 5:00 ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not BACK FLOW PROTECTDEVICE . 400 . . OCD. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA,COND. 5.00 intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- mealsarenotintendedorofferedforSale. IL however, the building - FIXTURES - PER TRAP 5.00 GAS - EA. SYSTEM -11INC. 4 OUTLETS 6.00 50. FT. FLOOR AREA TOTAL ACREAGE or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build orim prove for purpose of sole.). ❑ I, as owner of the property, am exclusively contracting with GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 BUILDING USE RES IND CON - PB Otner ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER3000 . . licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law docs not apply to an owner of propertywho builds or improves thereon. and who LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS- OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. contracts forsuch projeclswith a contraclods) licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑ Iamexemptunder Sec. ,B.&P.Gforthls reason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate ofconsent to self -insure, ZONING, ENG. SITE NO. or a certificate of Workers' Compeosallon•Insumnce, or a certified copy thereof (Sec. 3800, Lab.CJ..d Policy No. Company T�%G6N �z1.1.�F - ❑f.?Crlified copy is hereby furnished. �Certif coy is filed with he y inspecti division. Applicant CERTIFICATEOF-F.XEMPTION FROM W RKF.RS' FIRE SPRINK Y ❑ N ❑ ENERGY T-24 Y ❑ N❑ MISC. -. REFER TO ORD. PERMIT ISSUANCE 10.00 FLOOD ZONE A. L. U.C. COMPENSATION INSURANCE. (This section need not be completed if the permit is for one Y ❑ N❑ Y ❑ N❑ PLG. CONTR. LIC. NO. PLG. TOTAL hundred dollars ($ 100) or less.) I certify that in the performance of the work for which this per- mit is issued, I shall not employ any person in any manner so as to OTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of California. Date Applicant ALTER OR ADD TO MECH. 5.00 NOTICE TO APPLICANT: If, after making this Certificate of Ex- APPLIANCE 5.00 AIR HANDLING UNIT (TO 10=C.F.M.) 4.00 ' PLAN CHECK FEE emption, you should become subject to the Workers Compensation provisions of the Labor Code, you most forthwith comply with such provisions or this permit shall be deemed revoked. AIRHANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm ILat there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ.CJ, EXHAUST HOOD (WITH -DUCT) 5.00 MICROFILM HEATING UNIT (TO 100,000 B.T.U.). 8.00 I-ender's Name Lender's Address HEATING UNIT (OVER 100,000 B.T.U.) 9.50 ELECTRIC - V"d 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 and county ordinances and state laws relating to building construction, and BOILER -COMP (3 H.P. or 100,000 B.T.U.) 6.00 PLUMBING hereby authorize representatives of this,cily to enter upon the above-mentioned property for inspection purposes. BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL ' (We) agree'to save, indemnify and keep 1 rmless the City of MISC. - REFER TO ORD. Cupertino against liabilities, judgments, cost td expenses which may in any way acerae again said ity onsequence of the r ling of This permit CONST. TAX' PERMIT ISSUANCE 10.00 MECH. CONT. LIC. NO. MECH. TOTAL TOTAL ' ignalure of Applicant/Contractor Date OFFICE COPY J