6894 ,'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDINGPROJECT IDENTIF ION PERMIT NUMBER
„GILDING APPLICATION & MIT 6894
ADD ESS �� -
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL .
0 's PLAN CHECK VALIDATION
'/ 4S3 ICS TY. ELECTRIC PERMIT FEE --xa
b r / e - ONE 3J
�y N°MER" Rs OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No. LIGHTING FIXTURES 5.00/1.00
CDNTR ACTOR '
ADDRESS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE ' PANELS - 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR .
ENGINEER
LIC.No. ISIGNSTRANS. 3.00 •
ADDRESS ENG' SPECIAL CIRCUIT ,.5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
7PPLICANT'5 - MOTORS- SEE FEE SCH.
ADDRESS
SERVICE CHANGE 110.00 ll8
woo LICENSEDCONTRACfORSDECLARATION DE T994
1994
x-w
a U I hereby affirm that I am licensed unlet provisions of Chapter 9 ISSUANCE DATE
,<i (commencing with Section4000)of Division 3 of the Business and „LOQ ELECT. PLG. J MECH.
r m z Professions Code,and my license is in full force and effect. rs t",,,k C ppr}fn ❑
.o Z w W License Class' Lie.Number El la l U [1
In t DContractor
P ale, Cupertino BUILDING PERMIT.
ac,,. 4< •DWNER-BUILDER DECLARATION ?.t
R o a. U all TO ORD INFORMATION'
w ;a', 1 hereby affirm that I am exempt from the Contractor's License MISC.- - VALUATION S/FT.
F u U a Law 1'or the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 i
Code:Any city or county which requires a permit to construct,alter,
a2¢Fo improve,demolish,or repair any structure,prior W its issuance,also ELEC,CONTH. - LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL 6 ^ PERMIT TO'
A w m he is licensed pursuant W the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)O(Division 3 of the �rs0 7244
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
ce ce D STORIES TYPE CONSTR.
H o the basis for the alleged exemption-Any violation t to action malty
igm by any applicant fire permit subjects the SOO).)cantloacivil penally ALTER-DRAIN -WATER (EA.) 4.00
' of not more than five hundred dollars(5500).):
❑ I,as owner of the properly,or my employees with wages as - BACK FLOW PROTECT.DEVICE 2.00 DCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 4.00
Code:The Contractor's License Lew docs not apply to an owner of -
property who builds or improves thereon,and who does such work FIXTURES;PER TRAP 4.00 /p2-7 SO.FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are net intended oroffered for Sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or Improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving[hat he did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 El 0 1:1 0 0
❑ I,as owner of the.property,am exclusively cont4BUSinZ
ith
licensed contmetors to construct the project(Sec.704ess LAWN SPRINKLERS-1 INC 5 V.B. '5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law doelyto an owner of property who huilds or improves thereoho LAWN SPRINKLERS-OVER 5(EA.) 1.00contracts for such projects with a coutraclons)licensed tothe Contractor's License Law, - SEWER-SANITARY-S IE�1.200ft/8.00 TRACT NO. PARCEL NO.
❑-I am exempt order Sec. ,BAbis WATER HEATER W/VENT 4.00reasonOwner sjL(1 DateWATER SYSTEM 4.00 PCC.DATE ACC.FILE NO.WORKbq'COMPIiNSATIONDECLARATIOWATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsent tore, ertln0 ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No.'= . Con.Pany
01 ❑ Certified copy is hereby famished. FIRE SPRINK ENERGYT24
Z ❑ Certified copy is filed with the city+inspection division. MISc.- REFER TO ORD.
p .Applicant - Y [D N y N�
F- rn - PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > CERTIFICATE PE Ii XI!MPTINS FROM WORKERS'
CL _ COMI'ENSA'f10N INSURANCE PLG.CONTR. LIC.rv0. PLG. da v N v N
!L This section need not be completed if the permit is for one TOTAL
0 Z hundred dollars($100)or less.) `
U O '1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation'Laws of Califomia.
w
Dam Apphcam BUILDING s�
a ALTER OR ADD TO MECH. 4.00
} rn NOTICE:1'O APPLICANT: If,after making this Certificate of Ex.
� ? emption.you should become subject to the Workers'Cmnpensation' APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1O=CF.NL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000CEM35.00 SEISMIC FEE y-
I hereby affinn-thal 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.CJ. HEATING UNIT TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATI NG UN ,100,000 B.T.U.)7.50 ' ELECTRIC
I certify that l have read ibis application and state that the above VENTILATION FAN I5INGLE) 3.00
•' information is correct.I agree to comply with all city and county BOILER- PLUMBING pte
ordinances and state laws relating to building construction, and 3 ..or OO B.T.U.1 4.00
t hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes. BOILER-COMP Over 100,000„TUI SEE FEE SCH. ' MECHANICAL
(We) agree In Save, indemnify and keep harmless the City of MISC.- CIty Of UuperlfflitFER TO ORD.
Cupertino against liabilities,judgments,costs and expenses which CONST.TAX
may in any way accrue all a vid ity ia.cL ey`/'once of the PERMIT ISSUANCE 3.00 ,�' -
granting 0' is permit. ^/j MECH.CONT. LIC.NO. MEC
,lnFI/ IV- TOTAL 7 py TOTAL 16
/
✓Y Signa[ e o ppli 1/Contractor Date
- OFFICE COPY -