5473 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE-BALL POINT PEN ONLY
I ' PERMITNUMBER
BUI LDI NG'PROJECT IDENTIFICATION APPLICATION'& PERMIT -
ADDR SoorseS
DING-ELECTRICAL-PLUMBING-MECHANICAL 5473
OWNER'a p FF 1^+- q '' - -- PLAN CHECK VALIDATION
I • O,Ttis, ELECTRIC PERMITFEE ,.
ONE
O T AC O 5
DOUTLETS-SWITCHES-.RECEP 5.00/1.00xl� '1
Ic O. LIGHTING FIXTURES 5,00/1.00 _
r AcroR's - -
o SS le APPLIANCES;RESIDENTIAL 4.00
PANELS , ;S.00 DATE OF APPLICATION
OR
HIT S� SIGNS "I' '6.00 r, PLAN CHECK FEE P.C.NO.
EN IN EIC.NO. SIGNS TRANS. 3.00
ADDDRESS NG' SPECIAL CIRCUIT - 5.00 '- .PERdp�T�'14QATION
.
ZIP
EMP.METER OR POLE INS. 15.00 , UU
APPLICANT'S - MOTORS SEE _EE
SCH ,Q
ADDRESS APR,-2 5 1984 .
SERVICE CHANGE _ 10.00 - ,
o a o LICENSED CONTRACTORS DECLARATION City of Cupertln(
to U I hereby affirm that I am licensed under provisions of Chapter - ISSUANCE DATE
mz w coamencln•wi n 7000)of Division of the Ism
¢ y 6 BLDG. ELECT. PL MECH.
' �y z / Prolcssions CuJ�a y�licins is in lull far
z o Liccnu Clu ---c� M - ❑ ❑
n ractor _ it
-
a BUI UIN R.ERMIT4f.0
¢ a, w ¢ OWNER-BUILDER DECL R T 'kP,
F. o d D - MISC.- REFER TO ORD I FORMATIONtdx. r•• .
X g r I hereby affirm that 1 am exempt lima the retractor's Licenso
$/FT.
Hwo'a Law for the l'ollowingma...S.0ece.7031.S,Busi tessmoll'rofessions PERMIT ISSUANCE 6.00 VALUATION
E w 0 i Code:Any city or countypair any requires permit prior
to
i construct: also
ELEC CONTR. LIC.NO. ,
Lr¢O improve,demolish,or repair any structure.prior to its issuance,also ELEC. -
Oo u requires the applicant for such permit to file a signet statemnIt that TOTAL ,PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's Licenst,
Uzi
Law(Chapter 9(commencing with Section 7000)afDivision 3 of the F'
¢ Business and Professions Code)or that he is exempt therefrom and OTV'. PLUMBING PERMIT FEE ..
¢ rO the basis for the alleged exemption.Any violation ofSeclion 7031.5 STORIES', TYPE CONST
- a3m byanyapplicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.14.00'
of not more than five hundred dollars($500).1: -
❑ I,as owner of the property,or my employees with wages asggCK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their ale compensation,will do the work,and the structure is not
intended or offered (or sale (Sec. 7044, Business and ProfessionsDfl DRAINS-FLOOR,ROOF,AREA,COND. 4.00 "F.
Code:The Contractor's License Law don not apply to an owner of
prrperry who builds or improves lheronn,and whodriessuch work FIXTURES,PER TRAP 4.00 SG.FT.FLOORAREA TOTALACREAGE
himself or through his own employees.provided that such improve- .. .
ments are not intended oroffered Formic.Il',however,the building GAS-,EA.SYSTEM-11NC.40UTLETS 4.00
ar improvement is sold within ore year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
prove
l will have the buNen of proving that he did not built or I.
prove fors owner of sale.). - INDUSTRIAL WASTE INTER. RES IND0 CON PB Omit
❑ L as towner of the construct
he exclusively contracting with, 20.00 ❑ ❑ ❑ ❑ ❑
licensed contractors Contrathe project La does
Business LAWN SPRINKLERS-1 INC5 V.B. 5.00 ASSESSORS PARCEL NO.
to Professions property Contractor's improves
Law Aeo not apply ..
m an owner of property who builds or improves thereon,and who LAWN SPRINKLEflS-OVER 51EA.1 1.00 '
contracls for such projects with a contractods)licensed pursuant to - -
theCoutracuo'sLicenselaw. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B..OP.C,for this WATER HEATER W/VENT 4.00 ,
reason
Owner Date WATER SYSTEM' 4.00 ACC.DATE ACC.FILE NO,
WORK E-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 '
Thereby afrrm that I have a certificate ofccnsent to self-mm e, ZONING '
or a certificate of Workers'Compensation Insurance,or a cerlilied ENG.SITE NO. '
copy thereor(Sce.3600,Lab C.T. -
PolieyNo. Comp) `-
O 'C Certif klloMPENSATION
star y mashed, FIRESPRINK ENERGY T 24
_ z Z C Cer a s led ith the city inspection division.
O 1-i,{I'c`alit MISC. REFER TO ORD. yC] N❑ Y N❑
CC~ rn - PERMIT ISSUANCE - 6.00 FLOOD ZONE A.L.u.c..
,,,CIi11TIIi OE IiXEMPTION FROM WORK1iR5'
W > INSURANCE - PLG.CONTR. LIC.NO. PLG, -
0' O (This section need not be completed if the permit is for ane _ TOTAL Y❑ N❑ Y❑ . IN
D Z hundred dollars IS 100)or Icss.) - -m
t:J O 1 rertlfy that m the ped'ormancc o1'the work for which tins per- QTY. MECHANICAL PERMIT FEE FEECSUMMARV+f „•�
LL F mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Gtmpensalion Laws of California.
Date A licaut - BUILDING
a pP ALTER OR.ADD TO MECH. 4.00
} 0 NOTICE TO APPLICANT':.If;after reeking this CertiNcmc of Fe-
F,Z emptiou,you should become subject to the Workers Compensation APPLIANCE - 4.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed mvoked., AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONS'rRUCPION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 5.00 SEISMIC FEE
I hereby I from that there is a construction,lcnding agency for EXHAUST HOOD(WITH DUCT) 2.00
the perlornance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lemim's Name H EATI NG UN IT(OV ER 100,000 B.T.U.17.50 �0
Lender's Address ELECTRIC.
I certify that I have read this application and slate thal Ihe-above VENTILATION FAN (SINGLE) 3.00
-�• information is.correct, I agree to comply With all cily.and county - PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP.(3H.P.or 100,000B.T.U.) 4.00
hereby authorize representatives of this city to enler,upon the BOILER-COMP(Over 100,00013T01SEE FEESCH. MECHANICAL ,.
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep haralcss ora City of MISC.- REFER TO ORD.
Cu 'no a ainst liabil"' , ' dgmen 15 costs and expenses which CONST.TAX-'
m y i an ay ace a agar st said City in consequence of the PERMIT ISSUANCE'
nY of permi MECH.CONT LIC.NO. - MECH.
. . . TOTAL TOTAL-S,
j 3ignaturco Applicant/Contractor Dale �i
OFFICECOPV -