C7206 APPLICANT TO FRAJILIN INFORMATION WITHIN RED LIN - USE BALL POINT PEN ONLY
BUILDING PROJECIWNTI FICATIO14 PERMIT NUMBER
BIInDINo APPLICA ON & PERMIT y^O^
ADDRESS e2eq ( G b
L / BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S / ` PLAN CHECK VALIDATION
""�1 s a� ( 1 / TV. ELECTRIC PERMIT FEE
1--I�-ISA 4► + vRorvE . . .., _
CONTRACTORS' {// 21Q OUTLETS-SWITCHES-RECEP 5.00/1.00
U(dL ',bfA LIc,/No ` / LIGHTING FIXTURES 5.00/1.00
r.DNTRADrOR3 PPLIANCES-RESIDENTIAL 4.00
/ ADDRESS
+ oNE ' PANELS 5.00
S A(6j (/('ftp . SO3o / GATE OF APPLICATION
ARCHrtECT SIGNS - B.00 V PLAN-CHECK P.C.NO.
OR Gg 211
E
Ic.No SIGNS TRANS. 3.00 '
.R&.oR ENG �� ,SP ECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
Q v-Y.F .�( iIP 1 - EMP.METER OR POLE INS. 15.00 PAZ
APPLICANTS IMOTORS SEE FEE SCH.
ADDRESS
' I 11-,5 WIL{=1t. .� SERVICE CHANGE 10.00 'JUL 9 = 1985
wooLICENSED CONTRACTORS DECLARATION lI
¢ v u �I'Ferchy affirm that 1 um licensed under provisions of Clmpter 9 fUA
�H G A (,mumu••ncing with Section 7000)of Division 3 of the Business and BLD ELECT. I PLG, r,MECIL
r m z Professions Co ,211 my license is in lull I'orc•and effec ❑ ❑' ❑
z o In - Licens luss Lic.Number 3�
o z r o Dalc (Y' Contractor
BUILDING PERMIT
¢ ¢ ¢¢ OWNER-BUILDER DECLARATION INFORMATION
MISC.- REFER TO ORD
.-w 3 A r 1 hereby affirm that I am exempt from (he Contractor's License VALUATION $/FT.
F .. o g Law for the following reason.(Sec.7031.5,Bushiessand Professions PERMIT ISSUANCE i,' 8.00 y
Code:Any city or county which requires a permit to mnstmeL alter. /fr/1�\
ir
. W40 Improve,demolish.or repair any structure,prior to Its Issuance,also ELEC.CONTE. LIC.NO. ELEC. �(/ -
ZL e¢ requires the applicant for such permit to file a signed statement that TOTAL Q, PERMIT TO
A w m he is licensed pursuant to the provisions of the Contractor's License
H z Law(Chapter 9(commencingw'ith Section 7000)of Division 3 ofthe
¢
4 o Box tic.and Professions Code)or flirt he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H m the basis for tire alleged exemption.Any violation ofSectioa?031.5
penalty ST ES TYPE STR.
a ; - by any applicant for a permit subjects the applic�nttoueivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
r _ of nm more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 OCC.GRPVP RES.UNITS
their sole compensation,will do the work,and the structure is not 1
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 'K\
Code:The 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 4.00FT.FL00R AREA TOTAL ACREAGE.
. himselfor through his own employees,provided that such imt?ove- f ,
mems are not intended or otl'ered for sale.If,however,the budding GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
or improvement Is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA) 100 BUILDING USE
builder will have fire burden of proving that he did not build or im- . . .
IND CON PB Osber
prove for purpose of sale.). '�� INDUSTRIAL WASTE INTER. 20.00 KV
❑ I,as owner of the property,am exclueiuly contracting with ❑ .❑ ❑ ❑
licensed contractors to construct the project(SV 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 1 ASSESSORS PARCEL NO.
and Pfolessions Code:'I'lie Con ma.r's License Law dues not apply
to an owner of property who builds or improves thereon,and who LAWN SPR IN KLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractorfs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ lamexempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00 4
reason
Owner Dat, WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP. 4.00 ,.
I hereby affirm that I have a Certificate of consent to self-insure, v ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified x
copy ther�.p(f��e���JJ$$((1141. C.)-�• ' •
/- Policy No7A (YK onlp.ny
O ❑ Certified copy is herebyfurnished. FIRE SPRINK ENERGY T-74
Z z F1 CT) oqy Ly��red' h B5I�r By spuetion division.
�-- Applit"i GFa/ � o{')r.Ey[/�ias M•ISC.- REFER TO ORD. Y ❑ At Y ❑ N❑
r'rnPERMIT ISSUANCE 6.00 FLOOD ZONE A,L.U.C.
C1:R11171C I l?017 Ii XG.M PT IO NI'ROM WO RK E RS"
_ COMPENSATION INSURANCE PLG.CONTE LIC.NO, PLG.
EL 0 (This teclion need not be completed if the permit is for one TOTAL Y E] N❑ V❑ N❑
D z hundred dolh,s SI00)nr less.)
U O 1 certity that in the performance of fire work-4 which(]lis per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to n
OU become subject to fire Workers'Compensation Laws of California. VI
UJ Date Applicant BUILDING E�
a ALTER OR ADD TO MECH. 4.00
} to IV
NOTICE "f0 APPLICANT: IL after making this Certificate of Ex-
f- ? emption,you should become subject to the Workers'Compensation 2 APPLIANCE 4.00 PLAN CHECK
prTisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit she]]be decined revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCT ION LENDING.AGENCY AIR HANDLING UNIT(OVER 1000C.F.M.) 5.00 SEISMIC FEE A-
Ihereby affirm ilea there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of fire work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3897,Civ.C.). /3 -
L,ndm )7
'sName HEATING UNIT(OVER 100,000 B.T.U. .50 CTRIC
Lender's'Address
I certify that l have read this application and state that the above 3 VENTILATION FAN (SINGLE) 3.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction. and BOILER-COMP 13 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
aboomentioned property for inspection purposes. 3'
61,
Arrive
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Iia mile judgments, costs and expenses which r PERMIT ISSUANCE 3.00 CONST.TAX
may in y ay, a 'fire a cost said City in mrisequcnce of the
gran' / 'fi c hit. MECH.CONT. LIG NO. MECH. '
! TDTA TOTAL
a feo '
pplicant/Contractor ate -�
INSPECTOR COPY '