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12512 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER aD,Lo,NG APPLICATION & PERMIT AOORE55 �- BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12512 v1 i O"'NA NER'S PLAN CHECK VALIDATION NAME OTY. ELECTRIC PERMIT FEE 3 NAme acT.es UTLETS-SWITCHES-RECEP 10.00/1.00 LIC.NO. LIGHTING FIXTURES 10.00/1,00 p CONTRACTORS ADDRESS APPLIANCES-RESIDENTIAL 4.00 PHONE PANELS 10.00 DATE OF APPLICATION OR PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO. OR ENGINEER - sec.No. SIGNS TRANS. 3.00 ADDRRESS ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 APPLICANTS MOTORS SEE FEE SCH. ADDRESS ' SERVICE CHANGE 20.00 ,//51) 7 O O LICENSED CONTRACTORS DECLARATION T ¢ I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE Q < Gn w (commencing with Section 7000)of Division 3 of the Business and BLDG. EL,AE..C,,T, PLG. MECH. i Professions Code,and my license is in full force and effect. o 0 rut W License Class Lie.Number G Ex Date Contractor ¢ m f J BUILDING PERMIT ¢ ¢ w at 'OWNER-BUILDER DECLARATION INFORMATION E: ; H 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO,OR U.y m VALUATION $/FT. U. 00¢ Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 10.0 f w0i Code:Any city or county which requires a permit to construct,alter, ¢ ¢ ¢O improve,demolish,or repair any structure prior to its issuance,also ELEC.CO .NTRLIG.NO. ELEC. ¢ requires the applicant for such permit to Ole a signed statement that TOTAL D .-� PERMIT TO n w$ he is licensed pursuant to the provisions of the Contractor's License ^ H r Law(Chapter 9(Commencingwit)Section 7000).1'Division 3 oftha T�(]� T/�� a Business and Professions Code)or that he is exempt therefrom and QTY-F_ TV. PLUMBING PERMIT FEE 1 le f the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant too civil penally Z ALTER-DRAIN&VENT-WATER (EA.) 5.00 Q of not mare than five hundred dollars($500).): ❑ L,es owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS their sole com pensxtion,will do the work,and the structure is 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 is improves thereon,and who does such work FIXTURES-PER TRAP 5.00 a f!xa SO.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- mHaprovmerHismidor withinredf.yule.If,omplhowever,tionthe the Owner. GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 or improvement is sold within one year.(completion, the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE builder will have the burden of proving that he did not build or im- RES IND CON PB Other prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ED •❑ 11 ED as owner of the properly, exclusively contracting with licensedd contractors to construct thehe project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL No. and Professilonsons Code:The Contractor's License Law Joos not apply t0 anowner of property who builds t r improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a contraa].If s)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ 1am ex mpt and r Sec. .B.&P.C,for this WATER HEATER W/VENT 6.00 reason _ �- Owner s4Q( Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKER OM PENSA'1'ION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm ilial I have a certificme of consent to self-insure. ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO. copy thcreof(Sec.3800,Lab.C.L Policy No. Company Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24 Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD. p Applicant Y ❑ IN❑ v ❑ N❑ F' y PERMIT ISSUANCE 10.00 l w CC - CE RTI FICATE OF EXEMPTION PROM WORKERS' !O FLOOD 20rvE A.L.U.C. LU COMPENSATION INSURANCE PLG.CONTR, LIC.NO. PLG. q CL Z (This section peed not be completed if the permit is for one TOTAL ok Y❑ N❑ Y ❑ N❑ hundred d.11ars(S 100)or less.) U O I certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL H mil is issued,I shall not employ any person in any manner so as to V become subject to the Workers Compensation Laws of California. i Date ApplicantALTER OR ADD TO MECH. 5.00 _ BUILDING } N NOTICE TO APPLICANT: If,alter making this Certificate of Ex- � z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE I hereby affirm that there 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,CP.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 3 © Lender's Address ELECTRIC I C 1 certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00 PD information is correct.1 agree to comply with all City and county PLUMBING ordinances and state laws relating to building construction, and BOILER-COMP Q H.P.Or 100,000 B.T.U.) 6.00 16 hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEESCH. MECHANICAL ( above-mentioned properly for inspection purposes. d (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 (s CONST.TAX may in any way accrue against said City in consequence of the g li of this pe i. MECH.CONT. LIC.NO. MECH. /A TOTAL /S'2N TOTAL Signature o! licant//CCon Meter UaH, Q OFFICE COPY LT