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09605 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER r ADDRESS APPLICATION & PERMIT �� BUILDING Q + rd BUILDING-ELECTRICAL-PLUMBING -MECHANICAL OWNER'S PLAN CHECK VALIDATION NAME QTY. ELECTRIC PERMIT FEE J . eRorvE 7 NAMERACToas OUTLETS-SWITCHES-RECEP 10.00/1.00 "7 -./ m /0� UC.NO. LIGHTING FIXTURES 10.00/1.00 nooeCBS Tons APPLIANCES-RESIDENTIAL 4.00 t ' A- PRONE „' PANELS 10.00 DATE OF APPLICATION ARCmTECT - ��4 �� - PLAN CHECK FEE P.C.NO. oR �j'fS36 - PANELS (OVER 200 AMP) 20.00 ENGINEER LIc.NO, SIGNS TRANS. 3.00 ADDRRESS Ervc. SPECIAL CIRCUIT 5.00 P DnnoN APPLICANT', ZIP EMP. METER OR POLE INS. 20.00 SEP 0 4 1985 ADDRESS MOTORS SEE FEE SCH. o _ -_ > SERVICE CHANGE 20.00 City of Cupertino 0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE-,.F} 30.00 Q L,w I hereby affirm that I am licenaed under provisions of Chapter 9 TieISSUANCE DATE a (commencing with Seelion 7000)of Division 3 of the Business and H w BLDG. ELECT. PLG. MECq. i Professions Code,and my license is in full force and effect. - ❑ ❑ ❑ z o m - Licensc Cluss�226 LIc.N'um bcr„ y r w Dutc A�-a' L - ..O__--SC littrudorv:i �.• G!/ 3-fir \ BUILDING PERMIT IE lc re a WNER-BUILDER DECLARATION X 3 LL H 1 hurchy atfinn that I am exempt from Ihu Contactor',License MISC.- REFER TO ORD INFORMATION H u o v, Law for the following reason.(See.7031.5.Businessand Professions pERM1T ISSUANCE 10.00 VALUATION $/FT. to Code:An cit or count'which ret uires a - Y Y Y 1 permit to'onstruct,a mel 2 ¢ Q p improve,denmlich,lu repair any'structure,prior to its issuance,also ELEC.CONTR. LIC,NO. ELEC. 0 requires the applicant for such permit to file a sighed statement that TOTAL p M TO w w he is licensed pursuant to the provisions of the Contractor's License H z r Law(Chapter 9(cuntmencing with Section 7000)of Division 3 oflhe �( x c Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE li Ce H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPt CONSTR.. by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00 of not more than live hundred dollars(55001.): ❑ I,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 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 or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SN.FT,FLOOR AREA TOTAL ACREAGE . himself or through his own employees,provided that such PiRmve- Ricnts are not intended or offered for sale If,however,the budding GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00 or improvement is sold within one year of completion,the owner- builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE prove for purpose of sale.). INDUSTRIAL INTER. 30.00 RE IND CON PB 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 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 with a contractor(s)licensed pursuant to SEWER-SAMTAR Y-STORM EA.200ft/10.00 the Contract.,',License Law. TRACT NO. PARCEL NO. ❑ lam exemM under Sec. ,B.&I'.C.for this reason WATER HEATER W/VENT 6.00 If Owner DaleWATER SYSTEM 5.00 'ACC.DATE ACC.FILE NO. W'ORKERS'COMPENSAEION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate of consent m self-insure. or u certificate of Worker,Compensation Insurance,or u certified ZONING ENG.SITE NO. copy thereof'(Sec.3800,1.ab.C.IPoll `o(�'4.eompany ,G[_G-• ��yµ• Q 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. F O Applicant v N v N jrN CERTIFICA171017 EXEMI'IION FROM WORRIERS' PERMIT ISSUANCE 10.00 FLOOD 20NE AT.UC. W > COMPFNSATION INSURANCE PLG,CONTR. LIC.NO. PLG.-- d (This Section need hot be completed if the permit is for one TOTAL Y No Y No Z hundred dollars(S 100)or less.) U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F alt is issued,I shall not employ any person in any manner so as to 0w become subject to the Workers'Conipensut ion Laws of California. .a Daze Applicant BUILDING >- m NOTICE 'TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 F Z caption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you most forthwith comply with FEE U such m provisions or this permit shall be deeed revoked AIR HANDLING UNIT(TO 10j100CF.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOCRM.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 t D The performance of the work for which this permit is issued(Sw' MICROFILM 3097,Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 OO Lender's Name Lender,Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC 0 cantly that 1 have r 5�greesa cam ifi will)allstatec that Ne above � VENTILATION FAN (SINGLE) 4.00 • information n correct I agree to comply with all city and county PLUMBING ordinances and state laws relating to building construction, and BOILER-WA•tP(3 H.P.or 100,000 B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the H. BOILER-COMP (Over 100,000 BTU)SEE FEE SC above-mentioned property fur inspection purposes. MECHANICAL (We) agree-to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against li,bilitic,l,judgments, costs and expenses which CONST.TAX may in any-way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 granting of this permit. MECH.CONT. LIC.NO. MECH. TOTAL TOTAL afore of Applicant omraat Date �J•OD INSPECTOR COPY