4767 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ONPERMIT NUMBER
BOILDING APPLICATION & PERMIT ' ^ 67
ADDRESS � �V 4 I
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 7
OW„EF'S �.1 PLAN CHECK VALIDATION
"AME �•��( 0 OTY. ELECTRIC PERMIT FEE
;91WCONTRACT� acs ,v PHDs]E- d'3
OR$
„ ME a*7��l � UTLETS-SWITCHES-RECEP 5.00/1.00
�uc.No. U LIGHTING FIXTURES 5.00/1.00
rO TRACTORS /' ( APPLIANCES-RESIDENTIAL 4.00
0AiADDRESS /}}'[[�E�(rj�y '{'/!U
PHON[�(/ f / / PANELS 5.00 DATE OF APPLICATION
ORRCHUiECT SIGNS 6,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,No. - SIGNS TRANS. 3.00TFCH
'
/.CDR EOn ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ss
ZIP TEMP.METER OR POLE INS. 15.00 PAID
AANTS MOTORS - SEE FEE SCH, s
leeC SERVICE CHANGE 10.00 DEC 1983
o ¢ z
t
00 LICENSED CONTRACTORS DECLARATION /'s pp r
a z w I hereby ufllml Out I am licensed'under provisions of Chapter 9 _ CI UX r99A�IELInO
(commencing with Section 7000)of Division 3 of the Business and
G < m BLDG. ELECT. PLG. M H.
H N a Professions C n vaicense is in full furganJ,L-j1e - ❑ ❑
Z, L H o Littnse Class� �IVJ Lie.\u .,t- S_LkQ� El
Date�Iacuis Cnm rectorr_�_�,,_,,,� {/
Ha m s Wim, / BUILDING PERMIT
¢ a OWNER-BUILDER DECLARATION
a ¢ w v INFORMATION
w e- 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
town Law for the following reason.(Sec.7031.5.Businessand Professions pERM1T ISSUANCE VALUATION S/FT.
Code Any city or county which requires permit to construct,alter, 6,00
R2 ¢ improve,demolish,or repair any'structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w w he is licensed pursuant to the provisions of the Contractor's License
FII Law(Chapter 9(commencing with Section 700)o'Division 3 ofthe
a Business and Professions Code)or that he is exempt Therefrom and QTY. PLUMBING PERMIT FEE
¢ = S the basis for the alleged exemption.Any violas ion of Scctim 703l.5 ---STORIES TYPE CONSTR.
a3 by any applicant for a permit subjects the applicant to a civil Penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole cumpensulion,will do the work,and the Structure is not
intended or offered for In (Sce. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 sa FT.FLOOR AREA TOTAL ACREAGE -
• himself or through his own employees,provided that such improve
mentsare tie(intended oroffered for sale.l L however.me building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
ser improvement is.sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
b Tilde,will have the burden of proving that he did not build or im
prove for purpose of sale,' INDUSTRIAL WASTE INTER. , 20.00 s IND CDN PB Otis,
❑ 1,as owner of the property,um exclusively contracting with - ❑ ❑ ❑ 0
licensed contractors to ccri,ru l [lie project(Sec. 7044, Business. LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL No.
and Professions Code The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts the Contract suchLicense
cts Lwith acontractatls)licensed pursuant to SEWER-SANITARY-STORM'EA. 200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's License Low.
❑ I am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 4.pp
reason
Dae Owner WATER SYSTEM 4.00 Ace.DATE ACC.FILE NO.
WORK ERS'COMPENSA'TION DECLARATION WATER TREATING EQUIP, 4.00
1 hereby atfirm that I have a certificate of consent to elf-insure, ZONING ENG.SrtE NO-
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lxb.C.).
Policy No. Company
Q ❑ Ger1111ed copy is hur,by f...s cd' FIRE SPRINK ENERGYT24
MIS
Z 2 ❑ Certil icJ copy is filed with the city inspection division. ' C,- ' REFER TO ORD.
O Applicant YE] NE] Y E] NE]
~ va PERMIT ISSUANCE 6.00
LU - CIiR'I'IFICATIi FNSAEI N[ON NSUROAIWORAIiRS' FLOOD ZONE A.L.0 C.
CL COFf I'IiNSA1'ION INSURANCI! PLG.CONTE. LIC.NO. PLG. " Y❑ N v
Z (Thu section need not be completed if the permit is for one TOTAL N
CL hundred dollars(S 100)or less,
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I, mit is issued, 1 shall no unipluy ry ni ny munncr.w m to
U w Iwcony�ub'-cy��{pp tbb Workers C'x s sus of C:dilum' .
St. Darr/[ L�Appliwof _ ALTER OR ADD TO MECH. 4.00 BUILDING _
} N NO PLICANT: If,after makg l n Certificate of Fix-
comfort,you should become subject to the Wurkeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Lalur Code, you must forthwith comply wdll FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10A00CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNTT(OVER 10=17-F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
- the performance of the work to,which this pennit is issued(Sue. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lendeh Name HEATING UNIT(OVER 100,000 B.T.U.17.50
Lender's Add,.. ELECTRIC
I cantly lha Inoue rcuJ this applicaiotl amt state that Ole aboveif VENTILATION FAN (SINGLE) 3.00
ordinances n correct 1 agree to comply with all city and county PLUMBING
ordinances and orae• laws retailing c un ly with construction.andon, anJ BOILER-COMP I3 H.P.or 100,0006.7.U.) 4.00
hereby authon,e represenmrivcs of this city to enter upon the BOILER-COMP (Over 10.000 BTU)SEE FEE SCH.
above-mentioned property for inspect fon pugiwas. MECHANICAL
(We) agree to save, indemnify and keep harniless the City of MISC.- REFER TO ORD.
Cupertino against liahil' ins,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in ay cr a agumst Arid Ciry In conscyuentt oft e
gmnll 11's a L//� MECH.CONT. LIC.NO. MECH. f
TOTAL //
D SV TOTAL
lot
ofA plicant/Contractor Uatc a /
OFFICE COPY