6819 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENTI FICATION PERMIT NUMBER
auILrING . _ _ APPLICATION & PERMIT _ _ 6819
ADDRfs/5
4 �//1+'l/per AA/csr� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
NAMER S�f� O¢Tfwb Tln'a _ PLAN CH TION
_ Pe' OT=V. ELECTRIC PERMIT *aFEE
E NOV49
CORS
NAME UTLETS-SWITCHES-RECEP 5.00/1.00 2 31984
NAME
LIC No. LIGHTING FIXTURES 5.00/1.00 City of c
CONTRACTOR
s PPLIANCES-RESIDENTIAL 4.00 Perrino
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT ' SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ON
ENGINEERCj7Vq __. ///��/ SIGNS TRANS. 3.00
W� sec.rvo.
ARCH.OR ENG.7Z_1 �fti-n SPECIAL CIRCUIT 5,00 PERMIT VALIDAT ON
ADDRESS- /r
s5 ❑U- Se, CIA 2- zm EMP.METER OR POLE INS. 15.00 I
ADDRESNrs,3o7 S, m•A•�N .S-J'a r MOTORS SEE FEE SCH.
9 �•}' SERVICE CHANGE 10.00 11 A
woo LICENS17D CON'I'RAC ICAS DECLARATION
G v u I hemby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w s y (commencing with Section 7000)of Division 3 Of the Business and LDG ELECT. PLG. MECH.
H D i Professions Code,and my license is in full farce and effect. ElElz D m License Class Lie.Number
I El Q m E o Date Conlneou
a w Q
OWNER-BUILDER DE - ,:BUILDING PERMIT
REFER TO ORD -°' ?INFO RMA TION
E:
3 u r I hereby affirm That 1 am exempt from the Contractor's
hicensc MISC.- VALUATION m �S/FT.
E- .. oa Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00 nnn
ZA as Code:Any city or county which requires a permit to construct,alter, /S
Qu,1 Improve,demolish,Orrepalranystruclear,prior lV itsesuancC,also ELEC-CONTR. LIC.NO. ELEC.
o ac u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m lie is licensed pursuant to lire mov cions of the Contractor's License
r Law(Chapter 9(commencing with Section 7000)of Division 3 of the �� g
z G Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE �7 I2-� /•'1-���•
r 0 the basis for(he alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
w. F_. by any applicadtfor a permit subjects the applicant macivil penally ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).):
Cl I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEV ICE 2.00 DCC.GROUP RES.UNITS
their sole compensation,will to the work,mW The structure is nut -
intended Or offered for sale(Sec. 7044, Business and PrOI'esalom DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code-1 lie 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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mcm.,are not intended or offered for sale.ll',however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or Improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA.) 100 BUILDING USE
builder will have the burden of proving that he did not build or ire- . .
RES IND CON PB Othm
prove for purpose of sale.). INDUSTRIAL WASTE INTER.. 20.00
liceI,as owner of the property,am exclusively contracting with 1:1 El El 1:1 ❑
nsed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Codr'fhe Contractor's License Law does not apply
to an owner,of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
cnntmcts for such projects with a LxmOracrods)licensed pursuant to
We Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Ianlexcmptunder S. ,B.&P.C.I'or this WATER HEATER W/VENT 4.00
Owner Dare VulAIC WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMITNSA1ION DECLARATION WATER TREATING EQUIP. 4.00 '
I hereby affirm that I have a certificate of consent to wit-insure. TONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof)Sec.3800,LAC.).
Policy No Compmry
O ❑ CeHilicd copy is hereby furnished FIRE SPRINK ENERGY T 24
Z 2 ❑ Certified copy is Filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ N❑
~ naCO
LU 1 CERTII'ICI OP EXIiMFI'IPROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
11J COMPIiNSA'1'ION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
d ❑ ('Phis section need not be completed it the permit is for one TOTAL
Z hundred dollars(S100)or less.)
U O 1«reify that in the pedunn once of the work for which this ver- QTY. MECHANICAL PERMIT FEE FEESUMMARY
LL l- mil is issued,I shall not employ any person in any mammr so as to
U heconh's b)�e o'lie Workers'Com ensation Law of Calibrnia. BUILDING
n Il:nc,�i�i1.(�5/-Applies"r`S`�'/3AQ-lOx�+ry' LTER OR ADD TO MECH. 4.00
} W N(1'I1- 0•AI'1)I-ICAN'1': 11,vfr r making this Certificate of Ex-
2 emption,you should became subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit Strait be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 3.00
C'ONS'T'RUCT'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000GEM.) 5.00 SEISMIC FEE , 9
1 hcrcby mlinn that there is a eonstnmtion lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance�1 the work for which this p it is issued ISec. MICROFILM
3097,CiHEATING rCK HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name F HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lmulcr's nddrnx�'�Gl(�'Qy�_y�/J.i`� ELECTRIC
I certify that l have read this.pplicatimr and stale that Ofcobove' VENTILATION FAN (SINGLE) 3.00
. information is correct. I agree to comply with all city and county BOILER-COMP(3 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 city to enter upon the BOILER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL
Above-mentioned property for inspection purposes.
(We) agree to save, indemnify send keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs an x"a"ro"which CONST.TAX
may in any way accrue a ins i c quence of the PERMIT ISSUANCE 3.00
gra gof permit MECH.CONT. LIC.NO. MECH.
u / TOTAL TOTAL
ignalurcol'Applicant/Co tructur Dale �-•
OFFICE COPY'