5886 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICATION•' PERMIT NUMBER -
APPLICATION & PERMIT
BUILDING
ADDRESS l / �/
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 5886
OwNR'a EPLAN CHECK VALIDATION
Ii90
N E lu.gr Vida zsz� .
/p`I • QTY. ELECTRIC PERMIT FEE
Y J .V x,M PHONE
CONTRACT R'SPAID
NAME UTLETS-SWITCHES-RECEP .5.00/1.00
G:r.-p•- 'LIC.No. LIGHTING FIXTURES 5.00/1.00 n'q 196A .
TRACTORS
ADDRESS APPLIANCES-RESIDENTIAL 4.00
DOR
PHONE 1PANELS 5.00 OATS F
.C.NO.
ARCHITECT .. SIGNS 6.00 PLANC F
OR
E NGINEEn
' LIS.NO. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. SPECIALCIRCUIT '5,00 PERMIT VAL DATION
ZIP TEMP.METER OR POLE INS. 15.00 '
ADDRESS - - MOTORS SEE FEE SCH.
aooREs _
., SERVICE CHANGE 10,00 v
IAF w
02 LICENSED CONTRACTORS DECLARATION' -'
a u I hereby affirm that I am licensed under provisions of Chapter 9 _ ISSUANCE DATE
¢n
(commencing with Section 7000)of Division 3 of the Business and i B ELECT. PLG. MECH.
H i Professions Code,and my license is in full force and effect. ,
z o L License Class Lic.Number EI 1-1 E]
Q w' Date Contractor
a r E BUILDING PERMIT; ,
¢ ¢Be 4 OWNER-BUILDER DECLARATION INFORMATION -
oA MISC,— REFERTCl ORD
X ; ¢m I hereby affirm that 1 am exempt from the Contractor's License VALUATION $/FT.
Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE '6.00 - '
Code:Any city or county which mquires a permit to construct,alter, f,
¢ ¢¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
u w m u requims the applicant for such permit to file a signed statement that - - TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractors License �
F z r
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
< Business and'Ptofessions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
O A- IL—
BE
CONSTR.
¢r o the basis for the alleged exemption.Any violation t tSection malty
dam by any applicant fora permit subjects the applicant loacivil penahy ALTER-DRAIN&VENT-WATER (EA.) 4.00 +
of not mom than five hundred dollars(my em):
❑ has owner of the property;or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 P ES.UNITS
theirSalecompensation,will(S the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF;AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 AREA T ALAGRhimself or through his own employees,provided that such improve-
ments are not intended'or offered for sale.IL however,the building GAS-EA.SYSTEM-'I INC.40UTLETS "4.00
or improvement is sold within one year'of Completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILOIN USE
builder will have the burden of proving that he did not build or 6111- - RES IND PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑, 1,as owner of the property,am exclusively contracting with El ❑ El 11
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1-INC 5 V.B. - 5.00 ASSES$ $PARCEL NO.
and Professions Code:The Contractor's License Law does not apply -
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracthe Contractor's
Licenects Lwitharwntractor(s)licensed pursuant to SEWERSANITARY-STORM EA.2001t/8.00 TRACTN . PARCEL NO.
the Contractor's License Law. ,
Q.l am exe p under Sec. ' .B.&P.C.for this WATERHEATERW/VENT - 4,00 '
reason
Owner L� Date q-2'1 WATER SYSTEM 4.00 ACC.DATE ACO,FILE NO.
W RKER 'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that l have.a certificate of consent toiscirinsum, ZONING ENG:SITE NO.
or a certificate of Workers'.Compensation Insurance,or a certified _
copy thereof(Sec.3800,Lab.C.).
Policy No.- Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGYT-24
Z Z A❑I Certified copy-is .filed with the city inspection division. MISC.- REFER TO ORD. •y q y N
O pp'c ❑. ❑ ❑ ❑
H y PERMIT ISSUANCE . 6.00 FLOOD ZONE A.L.U.C.
W > COM
LU CERTIFICATE E EXEMPTION FROM WORKERS'COMPENSATION INSURANCE PLG.CONTR. ItlC.NO. PLG. -
1 O (This section need not be completed if the permit is for one - TOTAL Y❑ N❑ Y❑• N❑
Z) Z - hundred dollars(SIDO)"or.less.)
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL mit is issued,I shall not employ any person in any manner so as to x
V become subject to the Workers'Compensation Laws of California.
i Datc Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
}'rn NOTICE TO APPLICANT: If,after making this Certificate of Ex- '
? il
emplion,you should became subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE '
C,O such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10OWC.F.Iii 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.EM.) 5.00 SEISMIC FEE
I hereby affiim that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this,permit is issued(See. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C). -
Lender'sName
Lender's'Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
1 Certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
-information is correct:1 agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMPI3 H.P.Or 100,000 B.T.U.) 4.00 -
hereby aulhorim representatives of this city ti emer upon the 'BOILER-COMP IOvar 100,000 BTUI SEE FEE SCH. MECHANICAL'
- above-mentioned property for inspection purposes. _
(We) ag}ee to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gran[inf�Offy'is permit. per- MECH.CONT. LIC.NO. MECH. '
4��. 1i 9-12-84
TOTAL TOTAL
Signature of Applicant/Contractor Dale �•
" ::,I - - OFFICE COPY "