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09597 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER BUILDING gL0 APPLICATION & PERMIT ag5Q7 ADDRESS BUILDING - ELECTRICAL-PLUMBING-MECHANICAL t _ OWNE PLAN CHECK VALIDATION NAME• QTY. ELECTRIC PERMIT FEE vlsoNE t 2 Z cV NANTRAOT Rs NAME UTLETS-SWITCHES-RECEP 10.00/1.00 LIC NO.NO. LIGHTING FIXTURES 10.00/1.00 1.ADDRESS cro 's PPLIANCES-RESIDENTIAL 4.00 AD HONE PANELS 10.00 DATE OF APPLICATION ARaurEcr OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. ENGINEER uc.No. SIGNS TRANS. 3.00 ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 (.. APPLICANT MOTORS SEE FEE SCH. ADDRESS SERVICE CHANGE 20.00 p / woo LICENSED CONTRACTORS DECLARATION I TEMP.POLE 30.00 u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE n<m (commencing with Section 7000)of Division 3 of the Business and - - BLDG. ELECT. PLG. MECH. F wD z Professions Co�de,P2 4,1 my�li�ce�nse is in full force and effect. z o w - License Class�y Lic.Number V_'1 3 5'A r© 9 w Date Contractor a ms BUILDING PERMIT w OWNI!R-BUILDER DECLARATION INFORMATION oA MISC.- REFER TO ORD w a_ U I F r tire a.11. tum I am exempt from the Contractor License 6 Business and profcssimis VALUATION $/FT. F .. o a Lawforthe city or co rlyM ch requires PERMIT ISSUANCE 10.00 ac t- Code:Anymolishcoy ntywhicy regmmsepeiorIllt to mnsuanc .also ELEC.CONTR. LIC.NO. s( 0 improve,Acnxilish,or repair any structure,prior to its issuance,also ELEC. O u requires the applicant I'or such permit to file a signed statement that TOTAL PERMIT TO A w m he is licensed pursuant to the provisions ol'tire Contractor's License Fzi Law(Chapter 9(commencing with Section 7000)ofDivision 3of(lie a ' 4 Business and Provisions Code)or that he is exempt therefrom.and OTY. PLUMBING PERMIT FEE et F m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. - by any applicant for a permit subjects tire applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars(S500).1: ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS unended 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 Sp.FT,FLOOR AREA TOTAL ACREAGE himselforotinghbis ownemployees,fors,provf,ed that however.the improve- GAS-EA.SYSTEM-l 6.00 menu arc not intended or offered for sale,If,however.the building or Improd n - . - . . vemast is sold within one year of completion.the owner. GAS EASYSTEM OVER 4 IEA) 200 builder will have the burden of proving that he dill build Or am. BUILDING USE IND prove lepurposefsale.). INDUSTRIAL WASTE INTER. 30.00 flEs El CON ve Other 1,as owner of the property,am exclusively curl railing with El El ❑ El C1licensed contractors m construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Prufess'ionsCode:The Contractor's License Law docs not apply to an owner of property who builds or improves thcrton,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contruclsTorsuch,reject,with a Contracmrts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft110.00 the Contractor's License Law. TRACT N0, PARCEL NO. ❑ l ens cxcmpt Under Sec.-,B.&P.C.tin this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO, WORAERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby al firm that I have a certificate of consent to self-insure. ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO. copy thercof(Snc.3800,Lab.0). TT Policy NO. Company vF7-A T(l^"1 O ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY Tia Z 2 ❑ Certified opy is fi�leJs.�wI the ity inspection division. O APPlicC �� OL -•✓ MISC.- REFER TO ORD. Y❑ IN C:) Y ❑ N❑ � y C17RI'IFICAT'Ii OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLO. EL Z ('Ibis section need not be completed if the permit is for one TOTAL YE] N❑ Y ❑ N❑ hundred dollars($100)or less.) L) O 1 certify that in the performance of the work forwhich this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL 1- mit is issued,I Quill not employ any person in any Inanner so is,41 O beconm suhjcct to the Workers'Cmnpensation Lcvv,of California. n Dal° Apph,.Ut ALTER OF1 ADD TO MECH. 5.00 - BUILDING } to NOTICE TO APPLICANT: IL after making this Certificate of Ex- Z emption,you should become subject to the Workers'C'oUm,naatian APPLIANCE 5.00 PLAN CHECK provisions of the Labor Cade. YOU must forthwith Comply with - - FEE U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE 1-he®by affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 Ore performance of the work for which this permit is issued(Sec. MICROFILM 3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Fame HEATING UNIT(OVER 100,000 B.T.U.)9.50 Lender's Address ELECTRIC I certify that l have read this application and state that the above AJ VENTILATION FAN (SINGLE) 4.00 information as correct. 1 agree to comply with all city and county PLUMBING ordinances aiiiji to laws relating to building construction, and BOILER-COUP(3 H.P.or 100,000 B.T.U.) 6.00 hereby amhmitt representatives of this city to enter upon the BOILER-COMP (Over 100L000BTU)SEE FEESCH. MECHANICALS ♦ dd 5 abovc-mm�tioned property for inspection purposes. (we) agree to save, indemnify and keep hamiless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, tysts in nconsequences ofllthe PERMIT ISSUANCE 10.00 CJ rti CONST.TAX Cu in an way uccruc against said Cit granting of this permitMECH.CONT. LIC.NO. MECH. _ TOTAL & c13 I of Gon ra ate INSPECTOR COPY