4102 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
•1'
' BUILDING PROJECT lDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER4102
,j1UI1.oING _
aOORESS
'>C /0 N• O BUILDING -ELECTRICAL-PLUMBING-MECHANICAL -
OWNER'S _ PLAN CHECK VALIDATION
Na
DTV. ELECTRIC PERMIT FEE PAID
�f Wrt/) PRGNE
CONTRACTORS
NamE // / ' OUTLETS-SWITCHES-flECEP 5.00/1.00
DrbJ 0 �OLL. :/)U&IC.NO. LIGHTING FIXTURES 5.00/1.00 SEP 2 9 1983
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADURESs yn ��// f1xx��++���� f1ss I�AIW�nf1
Rg� Moat /-�s/E PHOdE 7 (o(e)' PANELS 5.00 tAlri7oQfAdb���i41t3N'
ARCHITECT SIGNS 5.00 PLAN CHECK FEE P.C.NO.
OR
t ENGINEER LIC,NO, SIGNS TRANS. 3.00
ARCH.On ENG, P MIT VALIDATION I
ADDRESS SPECIALCIRCUIT 5.00
ZIP EMP. METER OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE SCH. Q�
ADDRESS n, u
SERVICE CHANGE 10.00 n I� dry
woo LICENSED CON'rRACfORS DECLARATION
u u I hereby affnm.lhat 1 rum licensed under provisions of Chapter 9 ISSUANCE DATE
wQ A (commencing with Section 7000)of Division 3 of the Business am) B O ELECT. PLG. MECH.
2o - Pro(essimrs Cnde,and my license is in full brace and effect.
o'� License Class - Lic.Number EJF-1 El z 1- w Date (--2-/.-��3-Cctractor�K.��>LL
a s hIo I f BUILDING PERMIT
E rc w OWNER-BUILDER DECLARATION INFORMATION
-
wo e. MISC.- REFER TO ORD
; ,as I hereby affirm Ili at I am exempt from the Contractor's License
LLO ¢ I.aw for the following reason.(Sec.7031.5,Be,inessand Professions PERMIT ISSUANCE VALUATION $/FT.
Code:Any city or cou ity which requires permit to construct,alter, 6.00 S'
Q Q Q 0 Improve,demolish,Ot re PalT any structure,prior t0 its Issuance,also ELEQ CONTR. LIC.NO. ELEC. /
0 LL requires the applicant for such permit to TIC a signed statement that TOTAL PERMIT TO
w S he i5 licensed pursuant to the provisions of the Contractor's License y/�M
rZQ Law(Chapter 9(ecmmencing Willi Section 7000)of Division 3 of the
f i D Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
W 1- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ;� by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).).
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended Or offered for to (Sec: 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'rhe Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who.)nes such work FIXTURES-PER TRAP 4.06 SO,FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees. le.If,ed that such ibuildiprove,
ments are not through ,is onem,loffered for cesa rovideowever,the budding GAS-EA.SV$TEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4(EA.) 1,00 BW LDIN SSE
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.). • INDUSTRIAL WASTE INTER. 20.00 RES IND PB Osher
❑ 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 .ASSESS S RCEL NO.
and Professions Code The Contractor's License Law does not apply
to an owner of property who huilds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with n contractor(a)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200f1/0.00 TRACT NO. PARCEL NO.
❑ l am exempt under 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 self-insure•
or a certificate of Workers Compensation Insnance,or a certified ZONING ENG.SITE NO.
X copy thereof(Sec.3800,Iab.C.),
1 I )_ a
Policy No. Company-JOfd '�'-0
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
❑ 'Certified copy f�fed Ili t m tion division.
'AppliCant /�' MISC.- REFER TO ORD. Y❑ N[ Y❑ NE]
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W im_ COMPENSATION INSURANCE PLG.CONTH, LIC.NO. PLG.
Q (This section need not be completed if Ilse penin is for one TOTAL Y❑ N❑ Y ❑ N❑
Z hundred dollars(S IOD)or less.)
U O I certify float in firs performance of the Work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
ly mit is issued,I shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Laws of California. W
U y Date iApplicant ALTER OR ADD TO MECH. 4.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Corlil'icate of Ex.
F. Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forlhwilh comply will, FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10fWC.F.M) 3.00
CONS'T'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p000.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that (here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for'"whichthis permit is issued(Sec, HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.CJ, '
Lender's e
NamHEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Name ELECTRIC
I certify that 1 have read this application and stale first the above VENTILATION FAN (SINGLE) 3.00
ordinances n correct I agree to comply with all city and county PLUMBING
Ordinances and state lows relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon-the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the CityofMISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way Scrota against said Clty in conscyue co of the
grantingof ns omit, �/ p1 MECH.CONT. LIC.NO. MECH. S
/ �( 2G// J TOTAL TOTAL ����
'ignatr tApplicunt/Contractor U rt
OFFICE COPY