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8403 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENTI FI CATIO PERMIT NUMBER - ADILoiNo APPLICATION & PERMIT AooREss O A BUILDI G—ELECTRICAL—PLUMBING —MECHANICAL ®L.t O E 'S PLAN CHECK VALIDATION NAME QTY. ELECTRIC PERMIT FEE ^O� (LIDAJ//I - . NONE L _ C 3�L0 V rvrR cTORs UTLETS-SWITCHES-RECEP 10.00/1.00 v_ ss'4 IG, NAME ��� uc.No. r1 LIGHTING FIXTURES 10.00/1.00 s, w„C� rn ADDRESS 5173_ cp,sclim /SVNe PPLIANCES-RESIDENTIAL 4.00 W vnorvE PANELS 10.00 .-cs• DATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. OR NEER _ Lt..No J SIGNS TRANS. 3.00 ADDRESS �� _ .� f^;/lV Ia VY{ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION vKr, Zip C1 t- ' EMP.METER OR POLE INS. AooRess rs q( MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 P] D ¢ z F so LICENSED CONTRACTORS DECLARATION TEMP.POLE, 30.00 rev 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE a y'z w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. vH m i Professions Cod nd my license is in full force and effect ©` Z o T - License Class Lic.Nwnber� o m I Ix\ Date Can tractor_ a mBUILDING PERMIT ¢ ¢ w OWNER-BUILDER DECLARA'NON INFORMATION w.o' w I hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO ORD U_ Y 1 VALUATION $/FT. F ti 0Q Law for the following reason.(See.7031.5.Businessxnd Professions PERMIT ISSUANCE 7,Q,Q0 Q1 Code:Any city orcounty whichrequiresnpermit to construct.alter. /�� re ¢2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. PT1 y DLL requires the applicant for Such permit t0 file a Signed statement that TOTAL w, PERMIT TO w m he is licensed pursuant to the provisions of the Contractor's License - i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe S i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE ¢F o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. .. i3 `" .fn.1 byanyapplicant fora permit subJectstheapplicanttoacivil penalty ofnotmorethzr five herolit subjects the applicant ALTER-DRAIN& VENT-WATER (EA.) 5.00 ❑ I,as owner of the property,or my mnployceI with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.GROUP RES.UNITS their sole 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 4 A SII.FT.FLOOR AREA TOTALACREAGE himself or through his own employees,provided that such improve- �.� menu are not intended or offered for sale.IL however,the bud2.ding GAS 6.0000 "I, or improvement rs sold within one year of completion, GAS-EA.SYSTEM-OVER 4 [EA TL DING USE the owner- OC/ u builder will have the burden of proving that he did not build or im- f prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RS IND CON Pe Omer ❑ 1,as owner of the property,am exclusively Contracting with . . ❑ ❑ ❑ ❑ licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 N ASSESSORS PARCEL NO. and Professions Code:T'he Contractor's License Law does not apply to an owner of property who builds or iteprnvcs wereun,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 - Coniracls for such projects with a co"Lacto'LO licensed pursuant to the Contractor's license Law. SEWER-SANITARY-STORM EA.200ft/10-00 Vl. TRACT NO. PARCEL NO. C, am exempt under Sec. .It&P.C.for oris WATER HEATER W/VENT 6.00 ` anon Owner Date WATER SYSTEM 100 i Acc.DnrE ACC.FILE NO. WORK ERS'COM PF:NSA1ION HF(:LA RAT ON WATER TREATING EQUIP. 5.00 ! I m hereby affirthat I have it Certificate III coesent to svlGinsure, or d certificate of Worker.,'Compensalioe Insmwlee,Ur u certified ZONING ENG.SITE NO. copy thereof(Sec.3800,Lob.C.). Policy No. Conspany 1 1� 4 Q' ❑❑�cs`ertified copy is hereby luKd. FIRE SPRINK ENERGY T 24 r~ z Z pl vilified ropy is filed with the city inspection division. >-•' O AplllRicans r MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑ � N CERTIPICAft:Ol'.EXIiMPI'ION FROM WORKERS' PERMIT ISSUANCE 70 n0 d1I FLOODZONE A.L.u.C. Lu r COMPP.NSAT ION INSURANCE PLG.CONTR, LIC.NO. PLG. CL 0 (Phis section need not be Completed if the purmit is for one TOTAL Q Y❑ N❑ Y ❑ N❑ D Z hundred doIISrs(5100)orles0 U 01 certify that in the performance of the work fur which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY LL U mit is issued,I shall not eurploy any person in any manner so ax io become subject to the Workers'Compensation Laws of California. a Datn Applicant ALTER OR ADD TO MECH. 5.00 BUILDING }"W NOTICE TO APPLICANT: If.after making this Certificate of IN. F Z emption,you should become Subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you most forthwith comply with FEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MCF.M.) 4.00 4 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PWC.F.M.) 6.00 SEISMIC FEE 9.2 I hereby affirm that there is a construction lending agency for EXHAUSTAOOD(WITH DUCT) 5.00 0e performance of the work for which this Permit is issued(Sec. MICROFILM 3097,Civ C.). Q HEATING UNIT(TO 100,000 B.T.U.) 8.00 6A, r' Lender's Name r[t T '-`S •}'1 Lender's Andre _ .� �. +-T HEATING UNIT(01100,000 B.T.U.)9.50 ELECTRIC (J I Certify that I have read this appllcilkno and state that the above VENTILATION FAN (SINGLE) 4.00 information is correct.1 agree to Sqmply with all city and county -— PLUMBING 70 oNinances and slate laws relating to building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 6.00 hereby'authorize reperty tallies of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property for inspection of purposes. (We) agree to Save, indemnify and keep harmless the City of MISC.- ` REFER TO ORD. di Cupertino against liabilities,judgments, costs and expenses which CONST.TAX -` may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 10.00 /1 granting of this permit. MECH.CONT. LIC.NO. MECH. y TOTAL _� TOTAL r AP nt/Contractor Uarc /OJ•S^� INSPECTOR COPY r. IJ