4287APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICATION
'
& PERMIT
UILDING-ELECTICAL-PLUMBING-MEMECHANICAL
PERMIT NUMBER
4287 ^g7
BUILDINCAPPLICATION
AGGRESS
U�
owry R's
N ME
vISDN ��'
_ _ -
QTY. ELECTRIC PERMIT FEE
pLA Cj.MyI LIGATION
1Li
DEC 12 1983
CONTRACTOR
OUTLETS - SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES .5.00/1.00
LIC. NO.
Ito TE FiB pertino
GATE OF APPLICATION
cDNTRACTDR'a
AO REssrt- __N_-,_�. 1K -
i 07�� fT PHONE
APPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT
DR
ENGMEE �j
�! Llc. x0.7 O♦r� '
SIGNS � 6.00
PLAN CHECK FEE .L. NO.
SIGNS TRANS. .3.00
ARCH. OR ENG.
AOOIT
RES
PERMIT VALI DAT ON
EMP. METER OR POLE INS. 15.00
" ZIP
I
APPLICANT'$
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
-
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1
l
LICENSED CONTRACTORS DECLARATION
I harehy affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Cliffs- Lic. Number-
umberDate(_rZ__
ISSUANCE DATE
B D
ELECT.
❑
L MECH.
❑
Contractor
Date--- JV4fn&)�-
BUILDING ERMIT
INFORM TION
OWNER -BUILDER DECLARATION
1 hereby affirm that I ng so exempt from the Contractor's License
Law 1' Any citylorcountywhihn. e.uires a permit to and Professions
alter,
requires permit o its issuance,
improve, demolish, or repair any structure, prior n its issuance, also
imps: Any mulish county any structure.
requires the applicant for such revisit to file a signed statement that
he Is licensed pursuant to the of Cont License
MISC.- REFER TO ORD
PERMIT ISSUANCE 6.00
VALUATION
Or f
$/FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
QTY. PLUMBING PERMIT FEE
Law (Chapter Procosion,Code) with Section is exempt therefool the
ng withS Section 700 vivion
Business and Professions Code) or that he is exempt therefrom and
Ali
✓ (.fi{'
STORIES
TYPE CONSTR.
the bails for the alleged exemption. Any of Section
fora permit dollars $500).licam macivil penalty
he applicant malty
by any or than :
of not more than five hundred dollars (my
ALTER=DRAIN & VENT -WATER (EA.) 4.00
❑ I, as owner of the property, or my employees with wages as
em
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,CON D. 4,00
intended or offered for sale (Sec. 7044, Business and Professions
Cade: The Contractor's License Law does not apply to an owner of
-
'
FIXTURES - PER TRAP 4.00
GAS-EA.SYSTEM-11NC.40UTLETS 4.00
50. FT, FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsarenotintendedorofferedforsale. If, however, the building
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 IEA.) 1.00
BUILDING USE
REB IND LOG PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
licensed contractors 4a construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon. 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 it contractors) licensed pursuant TO
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec.-, B.&P.C. for this
reason
WATER HEATER W/VENT 4.00
Date owner
WATER SYSTEM 4.00
ACC.DATE
ACC. FILE NO,
WATER TREATING EQUIP. 4.00
WORK ERS'COMPENSATION DECLARATION
'
I hereby affirm that I have a certificate ofconsem to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof(Sec. 3800, Lab.C. C ,
Policy No.-Company..lLT�p11Y7L�
FIRE SPRINK
v ❑ N ❑
ENERGY T 24
, Y ❑ N ❑
❑ Certified copy is hereby furnished.
❑ Certifi• opy is fled with the city inspection division.
Applicant
MISC.- TO ORD.
CERTIFICATE P EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00 Oa
FLOOD ZONE
A.LdLC.
COMPENSATION INSURANCE.
(This section need -not be completed if the permit is for one
IT
PLG. CONTR. I L
PLG
TOTAL
Y ❑ N❑
V ❑ N❑
hundred dollars IS 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
JTQ S�
become subject to the Workers' Compensation Laws of California.
Date Applicant -
ALTER OR ADD TO MECH. 4.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become suBect to 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
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
PLAN CHECK
FEE
AIR HANDLING UNITIOVER IO,❑OOC.F.M.) 5.00 -
SEISMIC FEE
mss&)
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.CJ.
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's me
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Address
d
Lender's Addr
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER-COMP(3 H.P.or100,000B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorise representatives of this city on enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, cost's and expenses which
in any way accrue against said City in consequence of the
gr ImVAof this CITRIC
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO.
MECH,
TOTAL
TOTAL
Oo
Sigmtu plicant/Contractor Date
OFFICE COPY IQ