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3902APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTI F ON Bal DING APPLICATION & PWIT PERMIT NUMBER 3902 noon Ess UILDING-ELECTRICAL-PLUMBING-MECHANICAL O EH' - NAME OTY. ELECTRIC PERMIT FEE PLAN CHECK VA LIGATION - PHONE CONTRAC ORS `NNgy+Ie OUTLETS - SWITCHES -RECEP 5.00/1.00 (. �,,$Lq![.P uc. No LIGHTING FIXTURES. 5.00/1.00 CONTRACTORS s. • PPLIANCES- RESIDENTIAL 4.00 PANELS PANELS S.00 'HONE DATE OF APPLICATION ORRCH]TECT ENGINEER o. SIGNS 6.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 AARC. 08 DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION - ZIP EMP. METER OR POLE INS. 15.00 p J APPLICANTS - e ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 , LICENSEII CONTRACTORS DECLARATION I hereby affirm that I am licensed under providotu of Chapter 9 fern nmteneing with Section 7000) of Division 3 of the Business and Professions Coyy��Hmvo ,4y cense is in fu ,,j(syytc �yyl. License Class �,j_ Lic. NupP�kJ_ ISSUANCE DATE pLDG. ELECT. PLG. MECH. ❑ Date Comracml/pF.�ryJw-p�r�_ BUILDING PERMIT INFORMATION OWNER -BUILDER D ECLAAR`ATITIIO'rN Jcrc I hereby ctire ollo that I so exempt lice the Cnntl' nd Pus License Law fornycit mircgrcasohichrn. .uires a pennonessand Professions Cote: Any city or county which requirese permit mconsa issuance, alter, requires, demolish, or repair any structure, prior n its atemetalso requires the the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the )of f,imor's License 3 mane Low (Chapter 9 (commencingwith Section is exempt of t therefrom Business and Professions Code) or that he is exempt therefrom and MISC. - REFER TO ORD PERMIT ISSUANCE 6.00 VgLUATION SIFT' ELEC. CONTR. LIC. NO. ELEC. TOTAL OTV. PLUMBING PERMIT FEE PERMIT TO ?4 4 / lie basis for the alleged exemption. Any violation of Section 7031.5 STORIES TYPE CONSTR. by any applicant for a pmol subjects the applicant too civil penalty of not more than five hundred dollars (5500).): ALTER -DRAIN -WATER (EA.) 4.00 ❑ I, as owner of the property, or my employees with wages as their sole Compensation, will do the work, and the structure is not BACK F LOW PROTECT. DEVICE 2.00 OCC. GROUP RES, UNITS DRAINS LOOR BOF, AREA, COND. 4.00 intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law don not apply to alt ower of property who builds or improves thereon, and who Aoes such work himself or through his own employees, provided that u¢h improvc- 'ments are not intended or offered for sale. If, however, the building SO. FT. FLOOR AREA TOTALACREAGE . FIXTURES - PER TRAP 4.00 GAS-EA.SVSTEM-11NC.40UTLETS 4.00 or improvement is sold within one year of completion, the owner- "builder will have the burden of proving that he did not build or inr- GAS - EA. SYSTEM -OVER 4 (EA.) 1.00 BUILDING USE prove l'or Purpose of sale.). as owner of the Property, exclusively Contracting with RES IND CON PB Other El ❑ 1:1 1:1 11❑ INDUSTRIAL WASTE INTER. 20.00 licensedd m contractors construct the project (Sec. 7044, Business e to bildsContractor's License Law does not tapply owner of property who huilds to an owner of Code: lye who r improves who n. and who LAWN SPRINKLERS - 1 INC 5 V.B. 5.00 LAWN SPRINKLERS -OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. tr h ceno,projectsL with a conractor(s) licensed pursuant to t rased contracts Contraor ctor's ills Can tulle toffs l -t Law. SEWER -SANITARY -STORM EA. 200ft/8.00 L� TRACT NO. PARCEL NO. ❑ tum exempt under Sri. ,B.&IlC. for this Code reason ACC.DATE ACC FILE NO. WATER HEATER W/VENT 4.00 Gc:A Date - Owner WATER SYSTEM 4.00 ` 80 WATER TREATING EQUIP, 4.00 WORKERS'COMPFNSAIIONDIICLARATION 1 hereby affirm that I have a certificate ofconsent to self -insure, or a eertilicate of Workers Compansation Insurance, of n certified ZONING ENG. SITE NO, cCpy the f (Sec. 3800, Lab.C.).l��. Policy ❑ C tlif C To V Ilcoeby frnS lslmd. 'Certs"It fled Th file in Inslon division. FIRE SPRINK v N ❑ ❑ ENERGY T Za v N ❑ ❑ MISC- REFER TO ORD. PERMIT ISSUANCE 6.00 Li CERTIPICATV 017 FXEMP'IIUN FROM WORKERS' FLOODZONE A.L.U.C. COMP[ NSATION 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 (S 100) or Iess.) I certify that in the Performance of the work for which this per- mit is issued, I shall not employ any person to any manner so as to OTV. MECHANICAL PERMIT FEE FEE SUMMARY - BUILDING become subject to the Workers' Compensation Laws of California. Dme ApplicantALTER NOTICE '1'O APPLICANT: If, after making this Certificate of Ex- OR ADD TO MECH. 4.00 APPLIANCE 4.00 AIR HANDLING UNIT (TO 10=C. ,M.1 3.00 PLAN CHECK FEE emption, You should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE CONSTRUC'HON LENDING AG17NCY 1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 the performance of the work for which this permit is issued (Sec. 3097, Civ.C.), MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 4.00 Lender's Name Lender's Address HEATING UNIT (OVER 100,000 B.T.U.P.50 ELECTRIC VENTILATION FAN (SINGLE) 3.00 I certify that l have read this applieallnn and state that the above information is correct. I agree to comply with all city and county and state laws relating to building construction, and PLUMBING Uordinances BOILER -COMP (3 H.P. or 100,000 B.T.U.) 4.00 BOILER -COMP Over 100,000 BTU) SEE FEE SCH. MECHANICAL hereby authorize representatives of this city to enter upon the 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 andex Pmtses which may in any way accrue against said City in cons"I once of the gra g of this pennil. i. PERMIT ISSUANCE 3.00 CONST. TAX MECH. CONT. LIG NO. MECH. OTAL TOTAL ig ah • of pp tcanl/Conlmc or Datc OFFICE COPY