9389 APPLICANT TO FILL IN-INFORMATIONWITHIN REDLINES - USE BALL POINT PEN ONLY
' BU LDI NG PROJECT 1 DENTI FICATI ON - PERMIT NUMBER'
BulLDING APPLICATION & PERMIT
ADDRESS O
/ V / UILDING - ELECTRICAL-PLUMBING-MECHANICAL 9 3 8 9
OWNER'S t
NAME '
a '.x p�. gy k' � §Ts PLAN CHECK VALIDATION
l/URD QTY: j;�+ y +ELECTRIC PERMIT'"'YY E r FEE
Y7 orvE a D7 qY xa
CONTRACTORS
/J
W
i OUTLETS-SWITCHES-RECEP 10.00/1.00Z
/'/G LIC.No.. LIGHTING,FIXTURES' 10,00/4.00
CONTRACTOR'S -
AODRESs USI`7(/1/4,�� L PPLIANCES-RESIDENTIAL .4.00
75Q o ONE 38QQ PANELS 10.00 GATE OF APPLICATION
ORRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
- uG NO - SIGNS TRANS. 3.00
ARCH.OR
ADDRESS ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
NT S .ZIP EMP.METER OR POLE INS. 20.00
aool ESSS MOTORS - SEE FEE SCH.
;APAID
q 6 /Z/'G D .JU/lq SERVICE CHANGE 20.00 ,OCT 111985
, 00 ' LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 11"
Ilia i n 1 hereby affirm that I am licensed under provisions of Chapter 9
..sr w (commencing with Section 7000)of Division 3 of the Business and CE DATED
r w z Professions Cod and y license is in full for<'e m d efjget. BLD E f MECH.
Z 0 se o License Class _L�Lic.Number - ❑ ❑ ❑
wH Uafe Can El-
r
a wu OWNER-BUILDER DECLARATION x %BUI DINa�PERMI, iJ
ea cc u. w I hereby affirm that Dam exempt from the Contractor's License MISC.- REFER TO ORD - I F,YIRM4TION,r' 5`r {,
I� 0 < Law forlhe followingonson.(Sec.7031.5,Business and Professions 0,,� VALUATION
5 - PERMIT ISSUANCE 10.00
m � Code:Any city orrountyrep which structure permit m construct,alter,
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. - _
0 or requires the applicant for such permit to file a signed statement that 3 O✓/O C7 TOTAL(+/� E MIT TO
n w es he is Beeman pursuant to the provisions ol'the Contractor's License /
>
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe ��- -LT` s x "
g+
E o Business and Professions Code)or that he is exempt therefrom and DTV. . tl " 'PLUMBINGIPERMIT ..a'`d "_ EiFEE.Y£ 1
F. $ the basis for the alleged exemption.Any violation.(Section 7031.5 . '; t h z ' g{" STORIES TYPE CONSTR.
a3 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN v
of net inose than five hundred dollars(S500)J: (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the St ruclure is not OCC.GROUP 'RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP S.00 SQ FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve- -
. mentspre not intended or offered for sale.If,however,the building GAS-,EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the properly,'am exclusively contracting with -� O
licensed contractors to construct the project(See.,7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors 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 for such projects with a contractors)licensed pursuant to -
theContractor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/10.00 TRACTNO. PARCELNO.
O lam exempt under Sec. _ ,N.&P.C.for this WATER HEATER W/VENT 6.00
on
Owner Date WATER SYSTEM - 5.00 ,
ACC.DATE ACC.FILE NO.
WORKBRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
- I hereby affirm that I have a certificate of consent to self-insure,
or a certificate or Workers'
Compensation Insurance,or a certified ZONING ENG.SITE NO.
CopyyhNdt Pa 'P°uY'L -
0 ❑ Certified copy is hereby furnished.
Z Z CertifieedJdopy Is re d witq the,city inspection division. FIRE SPRINK ENERGY T.24
r0 Applicant q/•/� �PW`AY6 MISC.- REFER TO ORD. ❑'
Y N Y N
jr,y CERTI FICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
LD > COMPENSATION INSURANCE
Qk5
uc.No. PLG. N�CLo ffhts section need not be completed if the permit is for oneTOTAL Y N Y� Z hundred dollars/S100)orTessIV O I certify that in the perlbmance of the work for which this per r # '* r +sH mit Is Issued,I shall not em to on y MECHANICAL PERMIT fink' # 3 *tFEE SUMNIARVLL p Y y person in an manner so as to § i t'a FEE0become subject to te WorkersCompensation Laws ofCalifornia. Aq
Date ADD TO MECH. 5.00 BUILDING
2NOTICE'f0 APPLICANT: If,a0er making this Certificate OI'Ex-
empli.n,you should become subject to the Workers'CompensationE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
such provisions or this permit shall be deemed revoked. ING UNIT(TO 10,000QF.M.) 4.00CONSTRUCTION LENDING AGENCY ING 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(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO100,000 B.T.U.) 8.00 -
Lender's Name'
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC '
I`certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. 1 agree to comply with all city and county PLUMBING „
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.of 100,000 B.T.U.) 6.00
Hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(we) agreeto stole, Indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
May in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
grysyng of this permit. / _. 'p - MECH.CONT. LI0.NO. MECH. ,T, .
Tl
SI kkne vpi `� �Q ds- TOTAL .TOTAL':,`.
g pphca ontractor Date
` OFFICE COPY -