2134APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONL-1;�
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BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
RMI M ER
2134
ADOREBUILDINc n
AOORE55 �� U
Jo
OWNER'
NAMEY
I
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
T' PHONE
NANTRAcaoRs
UTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
LIC. NO, 2
CONTRACTOR'S
AGOREss
APPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
PHONE
DATE OF APPLICATION
ARIHIIICI
OR Itis -,-v., Vi _%
ENGINEER
LIC. NO.
SIGNS - 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
moo ESS ENc.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
z,P
965
ADDRESS
AOOREaa 'SERVICE
MOTORS SEE FEE SCH.
CHANGE 10.00cLICENSED
�/a y
CONTRACTORS DECLARATION
QF
I Inerehy affirm that I am licensed under provisions of Chapter')
(commencing with Section 7000) of Division 3 of the Business and
Professions Cod , it (cense Is in full for f t.
License ss ic. Numb
Date nlraaor_ y L7
ISSUANCE DATE
BLDG.
�
ELECT.
❑
PLG. MECH.
❑ ❑
/�'
JUN 0 1982
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from Ilse Contractor's License
Low for the following reason. (Sec. 7031.5, Rosiness and Professions
Cade: Any city or county which req ulres a permit la conslrucl, alter,
improve, demolish, or repair any SIRICILIM, prior to its Issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Low (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or (hat he is exempt therefrom and
LOl
IMISS.- REFER TO ORD
PERMIT ISSUANC 6.00
VA UATION
3� .l
$IFT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
RE�.w,,c
,
OTY. PLUMBING PERMIT FEE
the basis for file alleged exemption. Any violation of Section 7031.5
tt'' TQ RIES yyy PONSTCq.
by any applicant for a permit Subjects the applicant to a civil penalty
of not more than five hundred dollars (S500).1:L_c
_TAE
/f
ALTER-DRAIN&VENT-WATER(EA.)4.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the st stature is not
BACK FLOW PROTECT. DEV ICE 2.00
OCC. caouP
REB. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for Sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
moperly who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments are not intended or Wfio,d for sale. If, however, the building
FIXTURES - PER TRAP 4.00
50. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -1 INC.4 OUTLETS 4.00
ori
or improvement is sold within one year of completion, the ownery
builder will have the burden of proving that he did not build or
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
REB IND CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: "rhe Contractor's License Law does not apply
to an owner of property who builds or improves (hereon. and who
LAWN SPRINKLERS • 1 INC 5 V. B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO,
PARCEL NO.
❑ 14m exempt under See. ,R.&P.C. lin this
reason
WATER HEATER W/VENT 4.00
Date Owner
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to selGinsure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO,
copy thereof IS.. 3800, Lab.C.).
Policy No. Campany_�
❑ Certified
ort i Lied1:61+4 Js it with t Ie 'ty i
Applicant �7�
tion Division.
FIRESPRINK
Y ❑ N❑
ENERGY T-24
I Y ❑ N❑
MISC. - REFER TO ORD.
CIE RI'I 171CATI: 017 Ii XEMI'1ION FROM WORK Ii RS'
PERMIT ISSUANCE, 6.00
FLOODZONE
A.L.U.C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for Beo
PLG. CONTE. UC. NO.
PLG.
TOTAL
V ❑ N❑
Y -[:]N❑
hundred dollars IS 100) or less)
I certify that in the performance of the work for which this per-
mit is Issued, I shall not employ any person in :my manner o as In
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
e f
become subject to the Workers' Compensation Laws of California.
Date ApplicantALTEfl
OR ADD TO MECH. q,Op
NOTICE TO APPLICANT': If, after making this Certificate 0f Ex-
emption, you should become subject l0 the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
APPLIANCE 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
AIR HANDLING UNIT (OVER 10=C.F.M.)5.00
SEISMIC FEE
S -U
CONSTRUCTION LIiNDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
I herehy affirnn that there is a construction lending agency lin
the performance of the work for which this permit is issued (Sec.
3091, Civ.C.L
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's aJn•ss
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
ordinances and state laws relating to building construction, and
801LER-COMP(3H.P.or100,000B.T.0-) 4.00
PLUMBING
BAILER -COMP IDVor 100000 BTU( SEE FEE SCH.
MECHANICAL
hereby authorise representatives of this city to enter upon the
ahovwmertioned property for inspection purposes.
MISC. - REFER TO ORD.
PERMIT ISSUANCE 3.00
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against and City in consequence of the
gra li gof tl is permit.
I /� 1
r1-
MECH. CONT. LIC, NO.
MECH.
TOTAL
TOTAL
uS�O
Signa Ire of Applicant tractor Date
OFFICE COPY