3900 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI- POINT PEN ONLY
P ITNUMBER
BUILDING PROJECT IDENTI FICA710N APPLICATION & PERMIT 3900
euac:Nc
ADDRESS �1
�D l7S �r IOC /QUO kvy BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S `
NAME M�. L I fl A, '` C�, F F PLAN CHECK VALIDATION
rS CITY ELECTRIC PERMIT FEE
PHONE
NAMEPAcrOPs UTLETS-SWITCHES-RECEP 5.00/1.00 (/
Jrlb 0146 Al.°If LIc.No3lrfr /7 �. LIGHTING F IXTURES 5.00/1.00
CONTRACT -a
ADDRESS J7! raw}//C Aj FC1Cd L4- S PPLIANCES-RESIDENTIAL 4.00 ,
e- (,r/ Na' PHONE '9yS•aA.�) PANELS 5.00 DATE OF APPLICATION
ARCHITECT PLAN CH ECK FEE P.C,NO.
oR SIGNS 6.00
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARCO OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP' EMP.METER OR POLE INS. 15.00 PMO
AAPPLICANT
PLICA TS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 'AUG 111983
0 0 i
F o o ICENSED CONTRACTORS DECLARATION City 4 Cuyertino
F u � I hereby affirm that I am licensed under provisions of Chapter 9
Ps a% (commencing with Section 70001 of Division 3.f the Business and BLD ELECT E PLTE EC .
y i Professions Code d my license is in full fort an a feet
z o v, License Class - Lic.Number /�L
4 - Dale Contractor
E`a
w ¢ OWNER-BUILDER DECLARATION BU LDINO ERM(
- o A ° ' : INFORMATION '
X ; m I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
u0j Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION S/FT.
- Code: which PERMIT ISSUANCE UvU
P uta
Law
Any cityowing reyon.(Seeyui31.5.Bnninessan5trofessiep 6.00
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
e.
LL requires the applicant for such permit to file a signed statement that TOTAL
w $ he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Hsi
Law(Chapter 9(commencing with Section 7000)of Division 3 oftheC-7 /�
i o Business and Professions Code)Gr that he is exempt therefrom and OTY. PLUMBING PERMIT - FEE y/01 /-7,7 L�
Ie H$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant fora permit subjects S500).he licam toacivilpenalty ALTER-DRAIN
of not more than five hundred dollproperty,
o fmy employees
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 2.00GROUP qEs UNITS
their sole compensation,will(S the work,and the structure is not S3 /
intended or offered is ale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
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 4.00 sa FT.FLOG APER roraL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00 ^
or unpbuilder
will have
is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
pro 1. purposeas owner of the.). INDUSTRIAL WASTE INTER. RES Irvo CON PB oma,
❑ d as owner of the property.he exclusively contacting with 20.00 R" Y 11
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 L� ASSESSORS PARCEL NO.
and Professions Code:The honb Contractor's o License Law does not apply w� _ /0
to frowner ofproperty who builds or tonsvesthereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 OIC`
contracts for such projects with a con[anods)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No PARCEL No.
❑ tum exempt under Sec. .B.&BC.for this
reason WATER HEATER W/VENT '4,00 �� pfd
Data Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE No.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 rte-
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Workers Compensation Insurance.or a certified ZONINy ENt: RITE NO.
copy thereof(Sec.3800,Lab.C.). - /
Policy No. Company
O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY LZa
Z Z ❑ Certifie copy is fi d w' [he sty inspeption division.
FO Applicant MISC.- REFER TO ORD. Y �
CC W CF. IFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 J&OVFLOOD ZOrvE A.L.U.C.
L COMPENSATION INSURANCE PLG.CONTR. ❑c.No. PLG.
CL O (This section need not be completed If the permit is for one I TOTAL I v V s'❑ N� V ry�
Z hundred dollars($100)Or less.)
U O I certify that in the performance of the work for which this per- CITY NIECNANICAL' PERMIT ' FEE- `
FEEBUMMARY
U F mit is issued,I shall not employ any person in any manner so is to - '
become subject to the Workers'Compensation Laws of California.
Dale Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
�j NOTICE. TO APPLICANT: If,after making this Certificate of Ex.
F.. Z emption,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you mus[ forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10J=C.F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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 for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UN IT 100,000 B.T.U.)7.50 /
Lender's Address - ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER-COMP13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this ot
city o enter upon the
above-mentioned property for inspection pucity
t . BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL �J
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, casts and expenses which CONST.TAX
may i i s
Any way accrue agat said City in consequence of the PERMIT ISSUANCE 3.00
grant of this permit MECH.CONT, LIC.NO. MECH.
7_ II rj - TOTAL �
stare of ATOTAL /X,
pplicant/Contractor Date
OFFICE COPY PuJ• /S�
- - Y 3S• $a