4554 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES 7- USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT,NUMBER
BUILDING APPLICATION & PERMIT 4554
ADDRESS 1 1{f\l(L\�-
•_'�J 1 �O BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
- . - __.
' ,f "OWNER'S - PL ,ALIOATION
PRUNE,T ��'�-$Il{tI- TY. ELECTRIC PERMIT FEE
�t2rm LJG1V K1\►
CONTRACTORS-
ME ME �1 f-Y �-�' OUTLETS-SWITCHES-RECEP 5.00/1.00 DEC 1983
A\ {\ r�1 ,�ua NoQG)O TIO LIGHTING FIXTURES 5.00/1.00
CONTRACTORS o u ertino
DDUE s .[`t`{� SrAPPLIANCES 4.00 CIM p
�.1.J��1 PHONE -�f PANELS 5.00 DATE OF APPLICATION
ARCHITECT Ak) - SIGNS 600 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00 \ ^
zm EMP.METER OR POLE INS. 15.00
APPLICANTS
ADDDRESSDRESSMOTORS SEE FEE SCH. ,•\/I'/)`
SERVICE CHANGE 10.00 `
o o LICENSED CON']'RAC'rORS DECLARATION 1`
a
is u I hereby affrm that I am licensed under provisions of Chapter 9 IS N E ATE
y rt i (conlmencmg with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG.
F y i Professions Co a an 1'ccese,is in full f ❑ ❑ ❑
Z 0 n - Licens , 'ass. Lic. -
O 2 r O Date -t '� Contract r
F y- J
a >< s BUILDING PERMIT
Frt a OWNER-BUILDER DEC in the . '
iii 0 INFORMATION
.
; y I hereby affirm that I am exempt from the Contrac oro License MISO- REFER TO ORD
FaoJ
Law for the nycit following rtywhch e.requires
a permit to construct,
altos PERMIT ISSUANCE 6,00 VALUATION 5/FT.
Code:Any city or county which structur a permit to eonsuanc .lice
QQ Q Q Improve,demolish,or repair 00y rlNCtllre,priorto Its ISSIli1RCe,also ELEC.CONTR. IC.N0. ELEC.
0 u requires the applicant for such permit to file a signet)statement that TOTAL PER TO
A w m he is licensed pursuant to the provisions of the Co nmetor%License
Fz >
Law(Chapter 9(commenciog with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
IS $ the basis for the alleged exemption.Any violation of Section 7031.5 1 TORIES TYPE CONSTR,
age by any applicant for it perm it suhjcets the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($5001.).
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 2.00 OCC.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. 4.00
Code:T'lie Contractor's License law docs not apply to an owner of
property who builds or improves thereon,and who does such work ' FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve-
ments are not intended or offered emplo employees,
pa provided
t at S the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,lire Dwner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 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. 5.00 ASSESSORS PARCEL NO.
anA 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 1,00
contracts forsueh Projects with a contractono liecmed plmuunt to
The Contractor's License law. SEWER-SANITARY-STORM EA. 200ft/8.00 TRACT NO. PARCEL NO.
❑ I ala exempt un der Sec.- ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00
I hereby affirm that I have a certificate of consent to sol Ginsure, 20NIN0 ENG.SITE N0.
or a certificate of Workers'Compensation Insurance.or a unified
copy[herypfl}�e`! y b�rft�.
Policy e rr
Q ❑iC•rRfied py is hereby to tis11 FIRE SPRINK ENERGY T-24
fi{CCr fit i w 1 't sp 'v'so
Z 0 Applicant Misc.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
� y Cli It ICA'I'E OF EXEMPTION FROM MRKERS. PERMIT ISSUANCE 6.00 FLOOD ZONE A .U.C.
LU a COMPENSATION INSURANCE PLG.CONTH. LIC.NO. PLG.
CL Cl (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y [3 No
Z) Z hundrtddollars($1001or1esSJ
U 0 I certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL'F mit is issued,I Shull not employ any person in any manner so S to
O Q become subject to the Workers'Compensation Laws of California.
y Date ApplicantALTER OR ADD TO MECH. 4.00 BUILDING
} m NOTICE TO APPLICANT: IL after reeking this Certificate of Ex-
Z emption,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 deemedrevoked, AIR HANDLING UNIT(TO 10)0000F.M.) 3.00
CONSTRUCTION LENDING AGENCY - AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work I'll which this Permit is issued(Sce. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.0.50
Lender's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SIN 3.00
infornlatiort is correct I egret to comply with all city and County BOILER-COMP(3 H.P.Dr 100,000 . .U.) 4.00 PLUMBING
j ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter Upon the BOILER=C MP (Over B 1 E CH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
IS r F D.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3;00 CONST.TAX
may in any way accrue against said City in consequence of the
gm i of this'p unlit MECH)a AA .CONT, LIC.N0.
((�� ,{.fJ TOTAL
i sure of Applicant/Contractor Date �f{1 TOTAL
OFFICE COPY