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C9134 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER APPLICATION & PERMIT ADDRESSILDING 9134 � A.,v7A BUILDING-ELECTRICAL-PLUMBING-MECHANICAL v OWNER' 'PLAN CH ECK VALIDATION NAMEpTV. ELECTRIC PERMIT FEE • VAo / %r _JO.PHONE .Er _���// CONTRACTORS NAMEUTLETS-SWITCHES-RECEP 10,00/1.00 G'/L(- �C%',,,J uc.NO. _ IC- LIGHTING FIXTURES 10.00/1.00 CONTRACTORS ACORESPPLIANCES-RESIDENTIAL 4.00 AL �r'PRONE 143-Q2 .1 PANELS 10.00 DATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. OR O ENGINEER LIc,No. SIGNS TRANS. 3.00 ARCH. RCH isON s END, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP EMP. METER OR POLE INS. 20.00 ;y APPLICANT'S ADDRESS MOTORS SEE FEE 1 SCH. SERVICE CHANGE 20.00 1 /�� 0 SeSe o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 �L / a v U I hereby of irn that I am licensed under provisions of Chapter 9 IS UANCE DATE m2w (commencing with Section 7000)of Division 3 of the Business and Q a BLDG. ELECT. PLG. MECH. r w z Professions Code,and my license is in full force and effect. ' 0. -o License Class 'I Lic.Number T-2�-._�v_� El El 1:1 o w Date 14 �L� Contractor_ L���ti_ x re ��:t BUILDING PERMIT ¢ a A OWNER-BUILDER DECLARA'T'ION o a ° g MISC. INFORMATION w y 1 hereby attic that 1 am exempt from the Contractor,Lica,V, . REFER TO ORD - a o a Law for the following reason.(Sea 703).5,Nusinefirand Profendous PERMIT ISSUANCE 10.00 VALUATION $/FT` - Code:Any city or county which requiresLpermit toconstruct,alteq t K Q z improve,demolish,or repair any sdmcture.prior to its issuance,also ELEC.CONTE. LIC.NO. ELE (J EL m u requires the applicant for such permit to file a signed statement that TOTAC.L PERMIT TO a w the is licensed pursuant to the provisions of the Contractor's License Ww(Chapter 9(commencing with Section 7000)of Division 3 oftlle i o Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE /NTF-2/&C it- (c the basis for lite alleged exemption.Any violat ion of Section 7031.5 STORIES TYPE CONSTR. to by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more that five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS their wle 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 so.FT.FLOOR AREA TOTAL ACREAGE • himself or through his own employees,provided that such improve- nds are not intended or offered for sale.If,however,tINC. - mehe building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 or improvement is sold within one year of completion, the owner GAS-EA.SYSTEM-OVER 4(EA.) 2.00 builder will have the burden of proving Iliad he did not build or iia- BUILDING USE prove lir purpose of sale:). INDUSTRIAL WASTE INTER3000 RES IND CON PB Our, 13 . . 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 Contractors Liceosa:Law does not apply to an owner of property who builds or improves thereon.unit who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a contractogs)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00 the Contractors License Law. TRACT NO. PARCEL NO. ❑ lam exanpt under Sea ,B.&P.C.for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC FILE NO. WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent m mel Gic'em. ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO. copy thereof(Sec.3800,Lab 1 �� - PolicyNo. Com an � �A p ❑ Certil i,a copy.s he $ fu rt d FIRE SPRINK ENERGY T 24 Z Z ❑ Certified p�gr led )if, the it ction division. MISC.- REFER TO ORD. OCOApplicant���t�•d1E Y ❑ IN Y [:] N[- CER7'IFICAIFOP EXEMPTION PROM WORKERSPERMIT ISSUANCE 10.00 FLOOD ZONE -A.L.U.C. WCOMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ NE] Y ❑ NE] rL Z (This section need not be completed if the permit is for one TOTAL hundred dollars($100)or less.) U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT , FEE FEE SUMMARY LL F mit is issued,I shall not employ any person in any manner so as 10 O become subject to the Workers'Compensation Laws of California. WD0. mc Applicant BUILDING (� tis >_ 0 NOTICE TO APPLICANT: If,after making this Ce Nificute of Ex- ALTER OR ADD TO MECH. 5.00 / `a V F 2 emption,you should become subject to the Workers'Compensation APPLIANCE I 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SMC.F.M.) 4.00 CONSTRUCTION LENDING ACENCY AIRHANDLING UNIT(OVER 10=C-F.M.) 6.00 SEISMIC FEE f�0 I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 the purfornance 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 Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC I certify that I have read this application and state Ilhm the above VENTILATION FAN (SINGLE) 4,00 • information is correct. I agree to and ccomply with all city d county PLUMBING ordinances and state laws relating to building const ranco and BOILER-COMM H.P.or 100,000 B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL aboveementloned property for inspection purposes. (We) agree to save, indemnify and keep baruless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX may in any way accrue agar t said City in consequence of the gr/ant g of Ibis permit _ MECH.CONT. LIC.N0. MECH. 4 �// n -/V- OTAL TOTAL /s�(� �1 Ig ture"of1A p1iL nt/ onifictor )am INSPECTOR COPY.