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4622APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY BU I LD ING PROJECT I DENTIFICATI ON APPLICATION &..PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 4622 PLAN CHECK VALIDATION BUILDING ADD ss / „� /^ OWNER'S AME . /` 253 �5 CITY. ELECTRIC PERMIT FEE p� 0 QCONTRA ORs NAME UTLETS- SWITCHES -RECEP 5.00/1.00 LIGHTING FIXTURES 5.00/1.00 ' LIC. No. \l� VOL ICATION CONTRACTORS ADDRESS PRONE APPLIANCES RESIDENTIAL 4.00 PANELS 5.00 ARCRITECT OR SIGNS B.00 PL E K FEE P.C. NO. SIGNS TRANS. 3.00 ENGINEER LIC. No. AARCH. OR DDRESS ENG. SPECIAL CIRCUIT -5.00 PERMIT VALIDATION TEMP. METER OR POLE INS. 15.00 ZIP \ M ADDRESS rs. ADDRESS CH. MOTORS SEE FEE SCR. SERVICE CHANGE 10.00 lY 11 `� LICENSED CONTRACTORS UIiCLA Rd'fION I hereby affirm that 1 am licensed under provisions Of ChapLL•r 9 ISSUANCE DATE (commencing with Section 7000) of Division 3 of the Business and Professions Code, and any license is in full force and effect License Class Lic. Number BLDG. ❑ ELECT. I ❑ AG. MECH. ❑ Date Contractor BUILDING PERMIT . OWNER R -BUILDER DECLARATION I hereby affirm that I am exempt from the C'ontractor's License Law for the following reason, (Sec 7031.5, Businessund Professions Code Any city m - county which requires a permit to cunstrucL alter, improve, demolish, or repair any structure, prior to it, issuance, also INFORMATION MISC. - REFER TO ORD VALUATION $/FT. PERMIT ISSUANCE 600 . ELEC. CONTR. LIC. NO. -E C. he ui res the applicant for such permit to file a signet statement Li asehat re is licensed pursuant to the provisions ns of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and ,- TOTAL (y'/D T TO 1 ///VVV�`���IIIR///M"'JJJI QTY. PLUMBING PERMIT FEE STORIES PE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for u Renoir subjects the applicant to a civil penalty of not more than five hundred dollars 15500).1', ' gLTER-DRAIN-WATER IEA.14.00 ❑ 1, as owner of the property. Or my anploycca with wagexus their sole compensation: will do the work, and the structure Is not BACK FLOW PROTECT.' DEVICE' 2.00 OCC.GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 4.00 intended or offered for late (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 docs such work FIXTURES - PER TRAP 4.00 SO. FT. FLOOR AREA TOTAL ACREAGE himself or through his own employees, provided that such improve- ments are not intended or offered for sale. 11, however. the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00 wner- or in. provemunr is sold within ono year (if co;npletion, the own,,- build r ill havetilburden of pr mg that he did not build or int- builder pfOils 1 ) 101.1"U'= <I th property, em exclusively sivUy antra ling with GAS - EA. SYSTEM -OVER 4 IEA.) 1.00 BUILDING USE REB IND CON PB Omer ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 20.00 LAWN SPRINKLERS -1 INC5 V.B. 5.00 ASSESSORS PARCEL NO. Ied contractors to construct the Project (S 7044 Business eRP ofe.'sons Code: fh 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 con Ductor0o licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT NO. PARCEL NO. ❑ Iamexemplonder Sec. .B41'.C. lin this reason_ WATER HEATER W/VENT 4.00 Date_II- `U WATER SYSTEM 4.00 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 4.00 WORKS RS'COMPENSATION 1 iCLARA PION I hereby affirm that 1 have a certificate ofconsenl toself-insure, or a certificate of Workers. Compeosat ion Insurance, or a certified ZONING ENG. SITE NO. - copy thereof(Sec. 3800, Lab.C.). Policy No. Company ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24 ❑ Certified copy is filed with the city inspection division --------- ApplicantY ❑. N ❑ Y ❑ N❑ MISC.- REFER TO ORD. CERTIFICATE 01' EXEMPTION I'RONI WORKERS' PERMIT ISSUANCE 6.00 _FLOODZONE A.L.uc. PLG. CONTR. LIC. NO.PLG. TOTAL COMPENSATION INSURANCE (This section need not be completed if the permit is for one V❑ N❑ V❑ N❑ QTY. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars (S 100)or less.) 1 certify that in the performance ol'the work for which this per- mit is issued, 1 shall not employ any person in any manner so as to BUILDING become subject to the Workers Compensation Laws of California,-- Date Applicant ALTER OR ADD TO MECH. 4.00 NOTICE TO APPLICANT: IC after making this Certificate of Ex- emption, you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK provisions of the Labor Code, you'must forthwith comply with such provisions or this permit shall. be deemed revoked. FEE AIR HANDLING UNIT (TO 10=C.F.M.) 3.00 AIR HANDLING UNIT (OVER t0,000C.F.M.) 5.00 SEISMIC FEE CONSTRUC'HION LENDING AGENCY EXHAUST HOOD (WITH DUCT) 2.00 MICROFILM 1 hereby. affirm that there is a construction lending agency for the performance of the work for which this Remit is issued (Sec. 3097, Civ,CJ. HEATING UNIT (TO 100,000 B.T.U.) 4.00 HEATI NG UN IT (OVER 100,000 B.T.U.)7.50 ELECTRIC Lender's Name Lender's Address I certify that I have read this application and shape, that the above infonnalimh is correct. I agree to eonhply with x11 city and county ordiwnces and state laws reWing to building, a nstroclion, and VENTILATION FAN (SINGLE). 3.00 PLUMBING �O " BOILER -COMP (3 H.P. or 100,000 B.T.U.) 4.00 BOILER -COMP (Over 100,000 BTU( SE E F E E SCH. MECHANICAL hereby autlmriec reprexenndives of this city to enter Inion the above-mentioned property y for inspection purposes. - MISC.- REFER TO ORD. CONST. TAX - (we) agree to save, indemnify and keep huroless the Ciry of Cupertino aguinst liabilities, judgn.cut,, costs and expmises which may in any way accrue against sai City in conscyuena of the PERMIT ISSUANCE 3.00 MECH: CONT. LIG NO. MECH. TOTAL TOTAL L /D •:selling of this lit // /S igaatute Applicant/Conlruc(or - Dutc OFFICE COPY