5647APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I IDENTIFICATION,
APPLICATION & PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
5647
aOLLDING.
ADDRESS
OWNER'S
NAME
PHONE
T
DTV. ELECTRIC P,ERMI, FEE
V_, � , � W-k.1I ;;;;; . ' _ e'< .
PLAN CHECK VALIDATION
PAID'
JUL13 1984
�x1�,I t{ �/s� ,.yy
Wh'9DQWIVi)I�L010
NAM ACTOR S I t•UTLEL
E C. NOg/ /
-SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00!1.00
-oNTRACTO'
AOORass
ONE
APPLIANCES -RESIDENTIAL 4.00
PANELS 5.00
OR
OR
ENGINEER
sec. No. -
SIGNS 6,00
PLAN CHECK FEE P.C. NO,
1 '
SIGNS TRANS. 3.00.
ARC" OR ENG. 1
SPECIAL'CIRCUIT 5.00
PERMIT VALIDATION
' iIP
%
/�/
J' I
EMP. METER OR POLE INS. 15.00
Avvucnrvrs
ADDRESS
`
MOTORS SEE FEE
SERVICE CHANGE 10.000.00
(/
/J
LICENSED CONTRACTORS DECLARA'[']ON
-
I herchy affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Prnfcssi, a Code. n+_ �enu is in (sell Owe a Cft
Cluss_6( Lic. Number
��
ISSUANCE DATE
OG ELECT. I PLG. MECH.
❑ 1:1 ❑
D.
Dale �.>r/�- Contractor
� ,
OWNER -BUILDER DECLARATION
affirm that I am exempt from the Contractor's License
1 hereby the wrens Professions
Law forlyefollowing reuov.(Sec.airesa permit
Code Any mentallypair any structure p n
t
�, BUILIDINO�PAE RMI
. 'INFORMATION' '
MISC. - - REFER TO ORD
PERMIT ISSUANCE 6.00
VALUATION $/FT.
n
I/y to
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
coolish t is soiance, also
prior to its issuance, also
improve, demolish, or repair any Permit toff e a signed
requires the applicant loo such remit to file a signed actor's License
he is licensed pursuant to the provisions of the Contractor's License
I�
Lr �✓lJ
PERMIT O
s e
DTV. PLUMBING PERMITF,EE
-
Law (Chapterand Profession, Code) or Section is exempt thane o of the
Business and Professions Code) or that be is exempt therefrom and
the basis for the alleged exemption. Any violation oction 703t.5
by any applicant fora permit subjects tile to a malty
e applicant mcivil penalty
.of not Inure five tum drop dollars
ST IES
TYPE LON
ALTER-DRAIN-WATER(EA.)4.00
wnn
❑ Las owner of the property, or Por employees with wages as
myem:
their sale compensulinn, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
DCC. GROUP
RES. NITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 7044, Business eel Pwfeuions
'Code: The Contractor's License Law does not apply to an owner of
FIXTURES -'PER TRAP - 4.00
GAS-EA.SYSTEM-1. INC.4OUTLETS 4.00
property whooves
builds or imprthereon, and who does such work
himself or through his own employees, provided that such improve.
'melts are not intended or Offered In, sale. IL however, the building
SO. FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within (tile year of completion, the owner-
builder will have the burden of proving that he did not build or an -
GAS - EA. SYSTEM -OVER 4 IEA.) 1.00
BUILDING USE
prove for purpose of sale..
❑ L as owner of I exclusively contracting With
RES IND CON PB Olhet
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construct the project (Sec. 7044, of apply
construct he
frowner of Code: The Contractor's License Law docs not apply
to
to owner of property who builds or improvesened
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
t with a contractor(s) licensed pursuam to
pursuant t to
contracts for such License
the Contractor's License Law.
❑ lam exempt under Sea ,B.&P.C. for this
rl'asGn
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT N0.
PARCEL N0.
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORK ERS'COMPENSA'I' ION DFCLARA]AON
1 hereby affirm that I have a eerlificlne of consent m sel&insure,
ZONING
ENG. SITE NO.
or a cenifmate of Workers' Comp 1 nc cetlifiM
copy thereo f(Sec. 3800,
Policy N ymny).
Company_
_
rt
❑ Certified copy is hereby funds red.
Certifigd y(Ipy /s Ille Wltll Illy III{pCCt1On dIVt910n,
Appllcanl_G./r�aL/y -It
FIRE SPRINK
y C] N
ENERGY L24
Y NE]CERTIFICA9'li
MISC. - REFER TO ORD.
OF EXEMPT ION F OA1 WORKERS'
COMPENSATION INSURANCE
(Phis section need not be completed if the permit is for ant
PERMIT ISSUANCE 6.00
FLOOD ZONE• ;
Y ❑ N
A. L.U.C.
Y ❑ N
PLG. CONTR. - LIC. NO.
PLG,
TOTAL
hundred dollars IS loo) or less.)
1 certify that in the performance of the work for which this p'r'QTYi
ant Is issued, I s11all not employ any person in any manner so as to
MECHANICAL PERMIT FEE
SUMMAK " I
BUILDING
�O
become subject to the Workers' Compemation Laws of California.
Dale Applicant
ALTER OR ADD TO MECH. 4.00
NO'I'ICC TO APPLICANT: 11, after making this Certificate of E
APPLIANCE - 4.00
AIR HANDLING UNIT (TO 10=12-F.M.) 3.00
PLAN CHECK
FEE
emption, you should become subject to the W(trkers' Compensotiml
provisions of the labor Code, you must forthwith comply with
such provisions or this permit shall he deemed revoked.
AIR HANDLING UNIT (OVER 10=C.F.M.) 5.00
SEISMIC FEE
r
CONSTRUCTION LENDING AGENCY
I hemby affirm Del there is a construction lending ugency.fnr
the perlbnnance of tilt work for which this permit is issued (Ste.
3097, Civ.C..
EXHAUST HOOD (WITH DUCT) 2,00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.P.50
ELECTRIC
VENTILATION FAN (SINGLE) 3.00
1 certify that I have read this application and state that the above
infornetion is cortcet. I agree to comply with all city and county
re
ordinances and state laws mating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP IGVBt 100,000 BTUI SEE FEE SCH.
MECHANICAL
(We) agree to Save, indemnify and keep harmless the City of
MISC. - - REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which
may in any. way accrue against
/at City in consequence of the
to t'Ig of this PC
PERMIT ISSUANCE 3.00
CONST. TAX
MECH:CONT. LIC. NO. MECH.
TOTAL
+ s '-
TOT,AL`1'57
Q9
i tore I c Dae
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OFFICE COPY