3522 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFISON PERMI MBER
/ 811%�g0"4G APPLICATION & P*
IT 3522
AOdRESs
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OwrvER's Ss PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE PARI
PHONE
NTRacraHs UTLETS-SWITCHES-RECEP 5.00/1.00 _
AME cs3-yn(so3. MAY : 1983
LIGHTING FIXTURES 5.00/1.00
CONTRACTOR S + - APPLIANCES-RESIDENTIAL 4.00 -
AD0 EEE r 'p p City OL Cupertino
.� PHON 7 - ,may PANELS 5.00 DATE OF 1AP{P/LICCAYTIO,N1
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
NGINEER
LIC.NO. SIGNS TRANS. 3.00
AOCORESs ENO SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
AMOTORS SEE FEE SCH.
DRESS E55
ADDR
SERVICE CHANGE PAIrl 10.00 �4 /_ //`;
r o O LICENSED CONTRACTORS DECLARATION _ , [
a v u I hereby affirm that 1 am licensed under provisions of Cha pier 9 L� o ISSUANCE DATE
N a N (commencing with Section 7000)of Division 3 of the Business and -• BLDG. ELECT. PLG. MECH.
H or z Professions Co e, y license is in full fo ce plc Kt
i o m License ass Lic.Numb // 1-31iiL4�'
o i L w Date Contractor City of Cupertino
< Y F BUILDING PERMIT
Q w OWNER-BUILDER DECLARATION R
w0a. MISC.- REFER TO ORD '
3 a y I hereby affirm that I am exempt from Ilse Contractor's License VA9UAIqbN SIFT,
H . o j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 --
Code:Any city or county which requires a permit to construct,alter, �1 .y(
2 ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. _q QO Un I tln�
y O M requires the applicant for such permit to file a signed statement that TOTAL V{ O ` PERMIT TO
A' w m m he is licensed pursuant to the provisions of the Contractor's License
HZr Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
at I m the basis for the alleged exemption.Any violation of Section7031.5 ST RIES TYPE CONSTR.
i ; � by any applicant for a permit subjects the applicant toacivil penally
ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(4500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is ball
intended or offered for sale (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 docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACRPAGE
himself or through his own employees,provided that such improve=
meats are not intended or offered for sale.If,however,(be building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
.' or improvement i5 held within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have lim burden of proving that he did not build or - '
Move for purpose of CON PB Other
of sale.). INDUSTRIAL WASTE INTER. 20.00
RES IND
❑ I,as owner of(he property,am exclusively contract Ing with ❑ ❑ ❑ ❑ ❑
licensed contractors to construe( the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
m an owner of property who builds of improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 ��!]��
contracts for such projects with a eontractorfs)licensed pursuant to
the Contractor's License Law. SEWER-SANIT RM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. .B.&P.C.for this WATER HEATER WIVENT 4.00
reason
Dale Owner WATERS M ACC.DATE ALC.FILE NO,
WORKHRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent tb velf-insure, City of Cupertino ZONING
or a c�s�tiI to of War Ps'Co)♦ppr'ysalum Insurance,or a cerlifieA ENG.SITE N0.
Wig;o. pee -t�e- - ee 0U
Policy No. Cmnpany_ 1:r A-IrLD'
O ❑ Cerlit'ied copy is hereby furnished. FIRE SPRINK ENERGY T 24
L�Cerb o y [kit will y in eclion division.
z00 ApplicaVjtJ7c f- a1".y L-Fi' MISC.- REFEWTO ORD. Y ❑ N❑ Y N❑
~ wPERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
Lu CERTIFICATE PEXEMPTION PROM WORKERS'1J _ COMPFNSAENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. qq
CL O (Phis section need not be completed if the permit is for one TOTAL -s 6 60 Y❑ N❑ Y ❑ N❑
Z) Z hundred dollars IS 100)or less.)
U O I eery he performance of the _ his per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
UL I- mit is issued,I shall n s IM.oy�pBly I n In any manner so as to
O become subject to the W ITIb ensa[ion Laws of California.
C. Datc - bam ALTER OR ADD TO MECH. - - 4.00 BUILDING O(p
} m NOTICE.T LICANI': If,alter make this Certificate of E. '
? emplio on should become subject -the 1 orkers'Compensation APPLIANCE 4.00 0` PLAN CHECK
prov' ons of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING 10,000 C.F.M.1 '3.00
CONSTRUCTION LENDING AGENCY AIRHAND I NI ( C.F.M.15.00 . SEISMIC+FEE 7=
I hereby affirm that there is a construction lending agency for EXHAUS D DCT) 2.00
the performance of the work for which this permit is issued(Sea MICROFILM
3097,Civ.C.). - HEATING IT
Lender's Name tiDA-0 HEATING 0 ,000 B.T.U.17.50 ELECTRIC 0?0
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information correct. I agree to with all city and county PLUMBING
ordinances and stale laws relatingg to to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. _ MECHANICAL
tiO G
above-menoned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino agains liabilities,judgments, costs and expenses which CONST.TAX
may m any w' ac a a+ainst Said City in consequence of the PERMIT ISSUANCE 3.00
granti of thi p rm ' 1 MECH.CONT. LIC.NO. MECH.
1i•� TOTAL 7 0 TOTAL 140 A7
S' atureof Applicant/Conlructor Date
OFFIC9 DOPY -