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C8665APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION - f"� 1 APPLICATION & PERMIT V BUILDING - ELECTRICAL- PLUMBING -MECHANICAL PERMIT NUMBER 8665 almmrvc _ A oo RESS OWNE 'S . NAME s D C�g� - QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION PHONE _ NAME o's OUTLETS -SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 LIC, ND. DATE OF APPLICATION ADDRESS Das PAP0 I 4P D, ���1p �7 �y'S) FlII'*P� _ PPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 ARCH T PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. ENGINEER LIC. No. SIGNS TRANS. 3.00 ADD Ess ENO' - ZIP SPECIAL CIRCUIT 5.00 PERMIT VALIDATION a Cl TEMP. METER OR POLE INS. 20.00 APPLICANTS ADDDRESSDRESS zzsya _ MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 1 hereby affirm that 1 um licensed under provisions of Chapter 9. (commencing with Section 7000) of Division 3 of the Business and L seaS'RO;S Code, and m license is in full force' nd effect. License Class_e�_�._ Lie Number ISSUANCE DATE BL ELECT. ❑ PLG. MECH. ❑ ❑ Contrucmr� UILDIPERMIT 1' INFORMATION ATION WN OWM1'Ii R -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law Forthe following reason.(See. 7031.5. Businessandrrofessions Code_ Any city or county which requasia purnt it to ma canst, alter, requires helap ilia or for repair any structure prior to its iatement also for the rovNt t0 filof to signed requires licensed Ilsedp pursuant ont statactor's Lit that hr is pursuant the provisions of the Contractors License MISC. - REFER TO ORD PERMIT ISSUANCE 10.00 VALUATION _ $/FT. ELEC. CONTR. UC. N0. ELEC. TOTAL PERMIT TO - �orn� (Chapter en of Division 3 of the Law (Chapter 9 (commencing with Section is exempt Business and Code) or that h is exempt t and QTY. PLUMBING PERMIT FEE / file ,li,Rons the basis for the alleged alleged Anyviolationof Section i ES NS q. by any applicant fore permit subjects the applicant toacivil penalty permit malty of not more than five hundred dollars (5500).): ALTER-DRAINSt VENT -WATER (EA.) 5.00 ❑ I, es owner of the property, or my employees with wages as n, will do the work, and the stcture is not their role'cnnlp.ociiuru BACK F LOW PROTECT. DEV ICE 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 Contractor's License Law does not apply to as owner of FIXTURES -.•,PER TRAP 5.00 GAS - EA. SYSTEM - I INC.4 OUTLETS 6.00 SO, FT. FLOOR AREA TOTAL ACREAGE Property who builds or improves thereon, and who dors such work himself or through his own employees, provided that such iligno c- mentsarenotintendedorofferedfursale. ll', however, the building or improvement is sold within one year of completionthe owner - builder will have the burden of proving that he did not, build or im- GAS - EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDIN USE prove for purpose of self). ❑ 1, as owner of the property, am exclusively contracling with RES. IND co 11 PB oma, ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OV ER 5 (EA.) 1.00 licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of propeny who builds or Improves therron. and who ASSESSORS CEL NO. contracts for such projects with a contractimo licensed pursuant to the Contractor's License law. SEWER -SANITARY -STORM EA. 2001t/10.00 / TRACT NO. PARCEL No. - ❑ tum exempt lender Sec. ,B&P.C. Ibr this reason WATER HEATER W/VENT 6.00 ' Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WORKBRS'COMPFNSAT ION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a ctn ilicale of consent to sell -insure, or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy thereof (Sec. 3800, Lab C -j... Policy mpm,ylon pa. MISC. - REFER TO ORD. I, ❑ Cenrnifierl copy is hereby rens �Q' Certified Copy is filed with the city inspection division. AI'Olicant FIRE SPgINK Y N E]❑ ENERGY T 2 V N C]❑ CERTIFICATE OF EXEMPTION FROM WORKERS PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C. COM1IPENSATION INSURANCE t'I'his seclilin need nut be completed if the permit is for one Y Y [:] NE] PLG. CONTR. LIC. No. PLG. TOTAL hundred dollars 1$100) or Tess-) I certify that in the performance of the work for which Onix per- mit is issued, I shall not employ any person in any manner so as to QTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 PLAN CHECK FEE CmPOon, you should become subject to the Workers'Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked AIR HANDLING UNIT (TO 10=C.F.M.) 4.00 AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE its CONSTRUCT ION LEN'DIN'G ACENCY -I.hereby ufl'inn that there is a construction lending ageneY for the parroWamee of the work for which this permit is issued (Sec. 3097, Civ Com, EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Name Ch �� I� U mILendcr's NameAddress HEATING UNIT ER 100,000 B.T.U.)9.50 ELECTRIC VENTILATION FAN (SINGLE) 4.00 1 certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and slate laws relating to building construction, and PLUMBING BOILER- COMP(3 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL hereby entlonell property for inspection purposes. abuse. authored r.perLY for ec this city to enter upon the MISC. - REFER TO ORD. (We) agree to save, indemnify and keep I m ndess the City of Cupertino against liabilities, judgments, costs and expenses which may in a way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 CONST. TAX g lis pcnnit. �zilz. .0 MECH. CONT. LIC. NO. MECH. 46Z44 gn re f p I t1C lr o TOTAL TOTAL 3 INSPECTOR COPY