5925APfOLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
5925
BUILDING
ADDRESS/ S
sa ' �!�t��✓
OW NEH'$
NAMEIIJETV
�A1'-O�TY.
_ PHONE -
y
ELECTRIC, P4 RMI1T-�,�FEE"
F -' - T.r
PLAN CHECK VALIDATION
PAID
AUG 221984
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oAvlVFQpPlMEQehH1t0
CONTNAME
%£ DLL G�O/�Llc.No.
OUTLETS UTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
ADDRESS
PHONE
APPLIANCES RESIDENTIAL 4.00
PANELS 5.00
OR
ENGINEER,
LIC. NO,
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDREss ENc'
SPECIAL CIRCUIT '5.00
PERMIT VALIDATION ,
EMP. METER OR POLE INS. 15.00
ZIP
/1A
ASS
ADDRESS
DDREE55
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I herehy afIinn that I am lice aed under provisions of Chapter,9
(commencing with Section 7000) of Division 3 of the Business and
professions Code, and my license is in full force and effect.
License Class Lic. Number
955 DATE
LDG. E CT. PLG. MECH.
❑ ❑ ❑
Uale CDnlractor
BUILDING ItPERMIT-J
>-6--,---
' .+INFORMATION ..,_
CIWNF.R-BUILDER DECLARATION
I hereby, affirm elat I am exempt foam the Contractors License
Law for the following reason. (Sec. 7031.5, Businessand ProfessionsPERMIT
Code'Any city or county which requires a permit to construct, alter,
MISC. - REFER TO ORD
ISSUANCE 6.00
VALUATION S/FT.
ELEC. CONTH. LIC. NO. ELEC.
TOTAL
improve, demolish, or repair any structure, prior 10 its immulce, also
requires the applicant for such permit to File a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
(,/)
U��r
PERMIT TO
Law (Chapter 9 (commencing with Section 7000) of Division 3 of t he
Business and Professions Code) Or that he is exempt therefrom and
-
CITY.PLUMBING PERMIT FEE
�+
Li
thebasis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to o civil penalty
of not more than five hundred dollars ($500).):
STORIES
TYPE CONST .
0
ALTER -DRAIN -WATER (EA.) 4.00
❑ I, as owner of the property, Or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
Dcd, GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 4.00
intended or offered for sale (Sue. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 4.00
'
property who builds or improves thereon, and who does such work
hinssell or through his own employees, provided that such 1RIPmve-
meats are not intended or offered for sale. If, however, the building
SO, FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA:SYSTEM' -I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
-
GAS - EA. SYSTEM OVER 4 (EA.) 1.00
BUILDING USE
Pr< or purpose of safe.).
Cxl as owner of the property, am exclusively contracting with
RES IND PB Omer
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
tic is l contractors to construct the project (Sec. 7044, Business
m 1 Prufessionx Code: I'IIe COmraetoi s License Law does nut apply.
to an owner of properly who builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
A55E5ti PARCEL NO.
contracts for such projects with a contractor(s) licensed pursuant to
the Contmetur, License Law,
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO,
PARCEL NO.
❑ taco exempt under SR,d.&P.C. Our this
reason A/ /
WATER HEATER W/VENT 4.00
t)w"ncDate
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
- -•
1 herehy affirm that 1 have a certificate ofconsem to self -insure,
or n certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab C.).
'
Policy No. Company
❑ Cedified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.
Applicant
MISC. - REFER TO ORD.
FIRE SPRINK
Y ❑ N❑
ENERGY T.24
Y ❑' N❑
CI:R'rI FICATE OF EXFMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLooO ZOrvE
a. L. u.c.
.• COMPIiNSAI'ION INSURANCEPLG.CONTR.
('Phis x"tmn need not be completed If the permit is for one
Y ❑ N
Y ❑ N 1
LIC. NO.
PLG
TOT.AL
hundred dollars (S 1000or Ir..)
I certify that in the performance of the work for which this per-
mit is issued, I shall nut employ any person in any manner so ns m
OTY. MECHANICAL PERMIT FEE
FEErSUMM"ARV'° jh
BUILDING
�S
S(/
hecoma subject to the Workers' Compensation Laws of California
Date Applicant
ALTER OR ADD TO MECH. 4.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex.
APPLIANCE_ 4.00
AIR HANDLING UNIT (TO 1000011F.M.) 3.00
PLAN CHECK
FEE
emotion, you should become subject to file Workers' Compensation
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked
AIR HANDLING UNIT (OVER 10=C.F.M.) 5.00
SEISMIC FEE
g�
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address -
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
VENTILATION FAN (SINGLE) 3.00
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER- COW (3 H.P. Or 100,000 B.T.U.) 4.00
BOILER -COMP (Over' 100.000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the'
shove-mentianeJ property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
i
may wa c,mc against said City,in consequence of the
MISC.- REFER TO ORD.
PERMIT ISSUANCE 3.00
CONST. TAX
gra f Obi Omit.
MECH. CONT, LIC, NO.
MECH.
9- Az
TOTAL
TOTAL-,
V�f
o Applicant/Contractor Date
OFFICE COPY