17517 APPLICANT TO FILLIN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
BUILDING PROJECT I DENTIFICATION - '
PERMIT NUMBER
BUILOING APPLICATION & PERMIT
DORES$ - 17 517
A
SD V, � ��I✓E BUILDING-ELECTRICAL=PLUMBING-MECHANICAL
Gvmf R'$ Y N OHEgK VAy Ty ION
NAME / //••� QTY. ✓ E ICP MIT FEE I-\•!\✓N+_�Ln�•LJ1/LTJ
HONE
CONTRACTOR'S ^
NAME UTLET - ITCHES-RE EP 10.00/1.00 L t,��[��t( �.
-- M CLIC,No. O��ZZ LIGHTIN FIXTURES 10.00/1.00 Lugo-;;,
\�. ,-
rDNTRAGTors � PP I ES-REST NTI L 4. 4F ` _-L
CONTRACTORS
IOC R\" r�L
S / N .1;r., ONE N LS, 19100 . DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR ELS (OVER 0 AMP) 20.00 -,
ENGIN EER -
uc.No. SIGNS TR 3.00
• �:- ARC 0Ess ENG, SPECIA C UIT 5.00 PERMIT VALIDATION
i, E M T R OR POLE I S. 20.00 '
APPUCANTs O SEE FEE SCH. B
AOOR ESS . \
AtEIIEkICE CHANGE 20.00 -
o =_
D: DEC 2 3 1992
F o LICENSED CON'T'RACTOR$UECLA RA'T'ION -
¢ -U I hereby'affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE -
11 a w . (commencing with Scaion 7000)of Division 3 of the fro ilb oradLED L
wDi Professions Code,and my icense is in full for d effect. ° " - BLDG �6Lfi_C�:I D,vLG;s� MECH.
h z O w- License CIass2.�S+ 3 Lic.Numbc(_yglJ�L(n L 4mIt
�'ZF w Date I'j'7.Z L Conlraclor�yQ M ay! U �1� I ❑ ❑ ❑
a m-f �' BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION'
¢ n o INFORMATION
,W 2 a _ I hereby affirm that I am exempt from the Contractor's License SC.-
H a Law for the following reason.(Sec.7031.5,Busineuxnd Professions ERMI 'ISSUANCE .10.00 VALUATION S/FT.
. wF Code Any city or county which retimcsa permit to construct ahcr.
¢ ¢ ¢O improve,demolish,or repair any structum,prior to its issuance,also ELEC ONTR. LIC.NO. ELEC.
�.¢ rcgoires the applicant for such permil to file a signed statement that TOTAL PERMIT TO
'.W$m he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commcncing with Section 7000)o f Division 3ofthe -
a Business and Professions Codes or that he is cxmnpt IhcraGom and QTY. PLUMBING PERMIT FEE
re r $ the basis for the alleged exemption.An - ''
gc p he violation o to actiun ,n?lt, STORIES TYPE CONSTR.
i ; _ by any applicant fora permit subjects the toacivil penally ALTER-DRAIN -WATER (EA.) 5.00
_
of not more than five honored dollars(55001.1',
❑ I,as owner of the property,or my employces with wages as BACK FLOW PROTECT. DEVICE 4.00 ac.GROUP RES.unlTs
their sole compensation,will do the work,and the sDucture•i,not
intended or offered for sale(Sec. 7044: Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of v.
property who builds or improves thereon,.and who docs such work. ' FIXTURES-.PER TRAP n 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE.
himself or Ihrough'his own employees,provided that such improse-
meetsamnot intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is wild within pr year of completion'
omilerion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
owner-
build,,
I will have the burden of proving that hC did not the
or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER: 30.00 ElRES IND 'CON PB Omer,
ce L contractors owner of the properly,heir project Se .70",ing wish ❑ ,❑
a El F-1
no,Pro ions to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6:00 ASSESSORS PARCEL N0.
so
Professions Cada:The Contractor's o improve,
Low docs not apply.
co an owner of property who builds or improves Insed primmer
who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contrathe COma ctor'sor hceneeuwitha coniractoals)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Conlmcfor s-License Law. � TRACT NO. PARCEL NO.
❑- lam exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
Basan
Owner Dale WATER SYSTEM 5.00
ACC.GATE ACC.FILE N0,
WORK ERS'COMPENSATION DECLARATION, WATER TREATIN EQUIP. .00
I hereby affirm that 1 have o certifmine ofconaent to sel Giestm•; ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a.cersifkd _
copy thcmcf.(Sec. 800 I,ab. a. Gv ft
Policy No lrY T tf/ 2C t A
0 ❑ Cermiedc pY hs he mby furnislwd. FIRE SPRINK ENERGYTZA
Z Z `Q:-Cenife py is filed�Ih^t_hea�'-mafnrotioil division,' ..
O APPill p nr , MISC.- REFER TO ORD. YE] N v (] N[
N• [FICA XIi.\1 PTION FROM WORKERS' PERMIT ISSUANCE FLOOD ZONE - A.L.U.C.
Lu > COMPENSATION INSURANCE PLG.CONTR, LIC.NO. PLG. V N V NE]
-O (This section tied not be camp leted if the permil is for one TOTAL
D Z hundred dollars IS 100)or less.)
U O I certify that in the perfurnwnce ol'tire work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F' mit is issued, I shall not employ any pecan in any manrscr so as to
Obecome subject to lire Worker,'Compensation Laws of California
pat, t Data Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificme of Ex-
Z cmptioo,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
proorcvisions of lira labor Code, you must forthwith Comply with FEE
U such provisions his permit shat[be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this Permit is issued fSeC MICROFILM
3097,Civ.Cf. HEATING UNIT(TO 100,000 B.T.U.) 8.00
- --- Lender's Name' HEATING UNIT(OVER 100,000 B.T.U.)Lender:Address ELECTRIC
it certify that I have read this application and slam that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county' PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby aullmrize representatives of this city to enter open the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
%(WO agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichyCONST.TAX
' PERMIT ISSUANCE 10.00
may in anway accrue against said City in consequence of the i
(anti Of this permil + MECH.CONT, LIC.NO. MECH.
✓�✓-�� L- z.i L TOTAL TOTAL
gnature of Applicant/Contractor Dale
OFFICE COPY