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09611APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENTI FICATI ON APPLICATION &PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 0�� aUILDIN BUILDING GRESSi OWNER'S - _ NAME - QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION tf��PHONE /j µp ' NAM OUTLETS -SWITCHES-RECEP 10.00/1.00 �„ LIGHTING FIXTURES 10.00/1.00 c-ONTRACORS OGRESS APPLIANCES - RESIDENTIAL 4.00 ,y �/ _ 'ENE PANELS 10.00 DATE OF APPLICATION ARCHITECT�Y�',(-y OR T ENGINEER uc. No. b PANELS (OVER 200 AMP1 20,00 PLANCNECK FEE P.C. NO. SIGNS TRANS. 3.00 ADDRESS eNa. ZIP SPECIAL CIRCUIT 5.00 PERMLT VALIDATION AID 'C'fT SEP LL rr 8 EMP. METER OR POLE INS. 20.00 APPLICANTS ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 4 1985 �l p/� /-+ LICENSED CONTRACTORS DECLARATION TEMP. POLE 1 30.00 I l ureby al'Iinn that l am licensed under provisions of Chapter 9 ❑p {) SSI ANVE bqr/®Q I (conunencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class m. \m uber.�__����I - BLDG. ❑ ELECT. ❑ PLG. 4C ❑ , Dztc 5 .N • -z -`Eactor n -ycyJ OWNFR-BDI LDF-R DECLARATION 1 hereby al'11rm that 1 am exempt from the Contractor's License Law for the following reason. (Sec. 7031,5. Business and Professions Code: Any city or county which requires a permit to construct, alien, BUILDING PERMIT r INFORMATION MISC.- REFER TO ORD PERMIT ISSUANCE. 10.00 VA WATION S/FT. ELEC. CONTR. LIC. NO. ELEC. TOTAL improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file it signed statement that he is licensed pursuant to the provisions of the Contractors License FEBIT TO OTY. PLUMBING PERMIT FEE Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Searm 7031.5 STORIES PE CONSTR. by any applicant for a permit subjects the applicant to u civil penalty Of not more than I'Ive hundred dollar, ($5000.), ALTER -DRAIN -WATER (EA.) 5.00 ❑' I, as owner of the property, or my employees with wages as their SOIe coropenottion, will d0 the work. and the structure Is not BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA,COND. 5.00 intended or offered for Sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of FIXTURES - PER TRAP 5.00 GAS-EA.SVSTEM-1 6.00 SO. FT. FLOOR AREA TOTAL ACREAGE properly who builds or Improves thereon, shut who does inch work himself or through his own employees, provided that such improve- mems are not intended or offered for sale. IL however, the building 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- prove for purpose of sale.). ❑ 1, as owner of the properly, am exclusively contracting with - . GAS - EA. SYSTEM OVER 4 IEA) 2.00 BUILDING u5ER IND CON PB oma, 0 Q E] INDUSTRIAL WASTE INTERL 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA,) 1.00 licensed conlmoors to construct the project (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 ASSESSORSPARCELNO. contracts for Such projects with u contractor(s) licensed pursuant to Che Contractors License Law. SEWER -SAN V -STORM EA. 200ft 10.00 / TRACT NO, PARCEL NO. O 1 am exempt under Sec ,B.&I'.C. for this reason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC. DATE ACO. FILE NO. `WATER TREATING EQUIP. 5.00 W'ORKERS'COMPENSATION DECLARATION 1 hereby aflion That 1 have a certificate of consent Io Tel&insure, or a certificate o1' Workers Compensation Insurance, or u certified ZONING ENG. SITE N0. copy thereof (Site 3800, Lab.C.l Policy/No.cF�Conipany y- Certifmd copy is hereby I'urnisha. ❑ Certified copy is filed will, the oily impaction division. Applicant FIRE SPRINK YEJ N[] ENERGY T-24 V❑ NEJ I MISC.- REFER TO ORD. CERTIFICATE OI' EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. COb1PkiNSATION INSURANCE ('I his section need net he compleicd i1' the permit is for one Y E N ' V N� PLG. CONTR. LIC. N0. PLG. TOTAL hundred dollars IS 100) or I.ss.) I certify that in the performance of the work for which this per- mit is issued. I shall not employ any person in any mann.. So as to DTV. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of California. Date Applicant NOTICF--+TO AI'1'LICAN"f: It. after making This Certificate of lix- ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 PLAN CHECK FEE cnq+iion, you should become subject to the Workers' Compensation provisions of the Labor Cade, you mOil forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT (TO 10=CF.M.) 4.00 AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm that the a is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ.C.). EXHAUST HOOD (WITH DUCT) 5.00 n MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 p nn Lender's Name - 1 1-2 - - - Lender'sAddress'd HEATI NG UN IT (OVER 100,0008.T.U.)9.50 ELECTRIC I certify that I have read this upplicatioand Xle tbir_1I?above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and VENTILATION FAN (SINGLE) 4.00 nn PLUMBING BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL (We) agree to save, indenmify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit, MISC. - REFER TO ORD. PERMIT ISSUANCE 10.00 /o. on CONST. TAX MECH. CONT. LIC. NO. MECH. 7„n a , �� _ TOTAL 3.5-•00 TOTAL .yam IIure ofApplucan[C ntractor ` Daie INSPECTOR COPY