5417APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
PERMIT.NUMBER
^
BUILDING .- -
A RES
BUILDING -ELECTRICAL- PLUMBING - MECHANICAL
_
1�
OWNER' ---
' NAME l+ " -
Fns,
�" T PHONE 2 ia` = f969
�
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PAID
CONTRgCTOfl'S
NAMEUTLETS-SWITCHES-RECEP
5.00/1.00
ne ro LIC.Na.379s
APR 10 1984
LIGHTING FIXTURES 5.00/1.00
nooeess Ton's'
APPLIANCES - RESIDENTIAL 4.00
S 'Q PHONE 4W 337
ONTION
PANELS 5.00
AORRLHITECT fr
ENGINEER
L¢. NO.'
SIGNS 6.00
ANOCHEIGWIFEE P.C. NO.
_
SIGNS TRANS. ' 3,00 -
nooREss ExG.
SPECIAL CIRCUIT 5.00
/ PERMIT VALIDATION
- - zm
TEMP. METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS. ' .
2Z/ 5. (iRi D rpemoor'94r
MOTORS SEE FEE SCH.
SERV ICE CHANGE' 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm. that 1 am licensed under provisions of Chapler,9
(commencing with Section 7000) of Division 3 of the Business and
Professions Cod pnd license is in full for. teff _
License C Is G: d Lic. Number
Datn Contractor
'DATE
fci 42
-
BL G. ECT.
PLG.. MECH.
_
, LEI
.. �� O
BUILDING PERMIT
INFORMATIQN
OWNER-BUILDFR DECLARATION
I ln:rem, hy affirm that 1 am exempt frothe Contractor's License
Law for the following reason. (Sec. 703 1.5, Business and Professions
Code: Any city or County which requires a permit' to construct, eller,
improve, demolish, or repair any struclum, prior to its issuance, also
°requires the applicant for such permit to file a signed statement that
he is licensed pursuant to ing provisions of the Contractor's License
Lew (Chapter 9 (commencing with Section 7000) of Division 3 of the
MISC. - REFER TO ORD
PERMIT ISSUANCE 6.00
VALUATION
IMOD
-
$/FT.
.
ELEG. CONTR. 'LIC. NO. '_
ELEG
TOTAL
PERM ,
IT TO "
Business and Professions Code) or that he is exempt therefrom and
'the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for aperdre dolhvs $500).ire licant too civil penalty
of not more than fivehundredprop dollars (my em}
❑ I; is owner cibthe property, or my employees with wages as
[heir sale compensation, will Jo the work, and the structure is not
CITY. PLUMBING PERMIT FEE
` ALTER -DRAIN & VENT -WATER IEA.) 4;00
STORIES
'
TYPE CONSTR.
. .
BACK FLOW PROTECTDEVICE ' 200 '
OCC. GROUP
RES. UNITS
intended .,offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
DRAINS -FLOOR, ROOF, AREA,COND. '4.00
FIXTURES - PER TRAP 4.00
'-
GAS - EA. SYSTEM -1 INC.4 OUTLETS 4.00
property who builds or improves thereon,. and who does such work
himself or through his own employees, provided that such improve-
ments armnot intended or offered for sale. If, however, the building
50FL FLOOR AREA
.
TOTAL ACREAGE
,
or improvement Is sold within one year of completion, the owner -
builder will'have the burden of proving that he did not build or am-
Prove for purpose of the property,
❑ I, as owner of the ro art e
p p y, he project
contracting with and
Ped colons Cod to construct the project (Sec. 7044, Business
does not apply
una Professions Code: The Contractor's License s thereon,
to an owner of properly who ballon tr improves thereon, una who
with a contractor(s) licensed pursuant to
contracts for such License
theContmcmr'sLicenuLaw.
❑ lam exempt under Sec. ',B.&P.C. I'or this
reasonWATER
'n
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
S' IND ON ' B O 11 ther
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5`V.B. 5.00 -
ASSESSORS PARCEL NO:, " `
_-
•. - -
.TRACT
LAWN SPRINKLERS - OVER.5 (EA.)' 1.00 -
.
SEWER -SANITARY -STORM EA. 200ft/8.00
NO. .'
PARCEL NO.
HEATER W/VENT; 4.00'
Owner Date
WATER SYSTEM,4.00'-
ACL. GATE.'.-
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;
;: ZONING -
ENG. SITE NO. '-
or o certificate of Workers' Compensation Insurance, or a certified
Copyther�Q�1'(Sec.38&Lab.C.)p
PoIicY NoK�14%$pany nGYAL
❑ Certified 'opy Is erehy famished
J/
❑ CerUfletyJ/cop�y Fled/4wion the city inspection'division.
Applicenl/�J.�Z6� .-.r'
-
MISC.- REFER TO ORD.
FIRE SPRIN K.
y.� N�
ENERGY T 2
Y❑ N�
CERTIF'IICCA•TEOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seditin need not be completed if the permit is for one
PERMIT ISSUANCE 6.00
FLOODZONE
v Q N O
A.L,u.C.
Y. Q N �
PLG. CONTE. -' LIC. NO.
TOTAL •
hundred dollars 1$100) or less.)
I certify that in the performenec of the work for which this Pei-
mitis issued, I shall not employ any person in any manner so as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
-
'BUILDING
r 60
become subject lo. the 'Workers' Compensation Laws of California.
Date' Applicant,'
, NOTICE TO APPLICANT:,If; f F,x- after making this Certificate o
- ,
ALTER OR ADD TO MECH: 4,00
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10=0C.F.M.) 3.00
PLAN CHECK
FEE -
eioption, yoJ should become subject to the Workers' Compensation
provisions of'the Labor Code, you must,forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (OVER 16000 GEM.) 5.00 -
SEISMIC FEE,
.' CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a. construction lending agency for
the performance of the work for which this permit is issued (Sea
3097, Civ.C.).
EXHAUST HOOD (WITH DUCT) '2.00 `_
" MICROFILM
'
'
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address -
Addo
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
VENTILATION FAN (SINGLE)' 3.00. -
I Certify that I have pli
read thisapcation and state thatthe above
_
'-
'information is correct. I agree to comply with all city and county
,Ordinances and state laws relating to building construction, and
PLUMBING
'BOILER- OOMP 13 H.P. or 100,000 B.T.U.) 4.00
herebyauthorizerepresentatives of this city to enter upon the
,above-mentioned property for inspection purposes.
B01 L'ER-COMP Mail 100,000 BTUI SEE TEE BCH.
MECHANICAL'
(We) agree to save,.indemnify and keep harmless the City of
MISC. - . REFER TO ORD.
.CONST.
Cupertino; against liabilities, judgments, costs and expenses which
may in any accrue against said City in consequence of the
-PERMIT ISSUANCE 3.00
TAX
..
. _
Itrantin fthmit 1
MECH. CONT.. LIC. NO.
MECH.
/_/�
TorAL
TOTAL
r
Signatn a of A n;antiContraclot :--S"y`-Va e
OFFICECOPY
/'