6821 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
. BUILDING PROJECT IDENTIFICATION I PERMIT NUMBER
9UILDING -7 APPLICATION & PERMIT 6821
ADDRESS
Jonas- oa34 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
MANE SG`rP4QrV•-I� PLANRgM (DATION
1^ OTY. ELECTRIC PERMIT FEE
Ad
NAME gPBONE USfl'T/ N NOV 2 C 1984
ONTRA TONG UTLETS-SWITCHES-RECEP 5.0011.00
C.NO, LIGHTING FIXTURES 5.00/1.00
CONTRACTORS LIC. PPLIANCES-RESIDENTIAL 4.00 City of Cupertino
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS6 DD PLAN CHECK FEE P.C.NO.
OR
ENGINEER 1 U Ifla� '�T'�L� SIGNS TRANS. 3.00
sec.No
ARCH.OH ENG 2 L/6 5"1" "1V"l' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ra.-. Cfl L- zIP S 2,P EMP.METER OR POLE INS. 15.00
APPLICANT'S/��� S )�YV1q.. y .2 ., 2e MOTORS SEE FEE SCH.
ADDRESS r
�vn L '/O Sr 7 SERVICE CHANGE 10.00 I l
�oo LICENSED CON fRACEORS DECLARAI'ION -
u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w G u (commencing with Seelion 7000)of Division 3 Of the Business and BLD ELECT. PLG. MECH.
ca w i Professions Code,and my license is in'full force and effect. ❑
z o w License Class - - Lic.Number El
o z F w Date. Contractor
BUIL-DINGTEHMITA,"
Ie.w a( OWNER-BUILDER DECLARATION
o MISC.- REFER TO ORD INFi.&WAT_ION;!P- -
w3 LL N 1 hereby affirm the.I am exempt from the Contractor's License VA TION S/FT.
F ..
Oat
Law for the following reason 15ca 703 L5,Business anJ Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires permit to construct,alter,is ca
/
oimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
DC requires the applicant for such permit to file a signed statement that TOTAL PERM( TO
u w se" he is licensed pursuadt to the provisions of the Contractor's License
Fa, Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the
a
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE F2dSGHe.a.
F a the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d;� by any applicant for a permit subjects the applicant lO a civil peDBlty ALTER-DRAIN&VENT-WATER (EA.) 4.00
Sno mom than five hundred dollars($500).),
I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
(bur sole compensation,will do the work,and the structure is not
nlonded or offered lou sale(Sec. 7044, Business and('sessions DRAINS-FLOOR,ROOF,AREA,COND. 4.00'
Code:The Contrador'.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.ET FLOOR AREA TOTAL ACREAGE
himself or Ibmugh his own employees,provided that such improve-
mentsare not intended or offered for sale.if,however,the building GAS-EA.SVSTEM-11NC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose ol'sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors In construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Pmfirssiov Code:The Contractor's License Law does a.I apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contrams for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
Cl III mPvxcmmptundcrS, ,BAP,Cfm Oli, WATER HEATER W/VENT 4.00
let0`A
ory-')
Ow G' Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPEN'SA'IION DECLARATION + WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate'ofcono nt Io self insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a Lerlified
copy(hereof(Sec.3800,Lab.CJ.
Policy No, Company
O ❑ Certified COPyisherebyfurtished. FIRESPRINK ENERGY T 24
Z z ❑ C,nified copy is tiled with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
N C Ii RI'1 l'ICA'I'E OP EX 17M PITON PROM WORKERS' PERMIT ISSUANCE 6.00FLOOD ZONE A.L.uF.
OJ > C'OMITNSATION INSURANCE PLG.CONTR; LIC.NO. PLG.
d 1'I'his section need'not he completed if the permit is for one _ TOTAL Y❑ N❑ Y ❑ No
Z hundred dollm,($IU()or less,)
U O I ccni(y I'm
in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY-
EL F- (nit is issued, I shall not unploy any person in any manner so as lo
U W bLmineu}�jccyyyyto the Wnrkcri Compcnsatipn Laws of Calif o"ma. BUILDING
DmcL(.A The:urt C:V W AL ER OR ADD TO MECH. 4.00
} tan '01 IC AN CAN(CAN'T: If,after making this Certificate of I:x-
I- Z Brom ion,you should hLeome subject to the Workers'Compensation APPLIANCE - 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such pr.vismrv,or this permit slmll be deemed revoked. AIR HANDLING UNIT(TO lO=CF.M) 3.00
CONS'fRUCfION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the pcoiumance o he work for which this per t rs issued(Sec. MICROFILM
3097,CizCd. 1/'*N2it+t HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000B.T.U.)7.50 ELECTRIC
Lender's Address
I rtify that I have rcaJ this application an
« d state that the above VENTILATION FAN (SINGLE) 3.00
. infornution 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 authorise representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. -
(We) agree to save, indemnify and keep hzrmhss the City of misc.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
gmnlingof this perm if. MECH.CONT. LIC.N07 MECH.
TOTAL TOTAL
Signature of Applicant/Contractor Date
OFFICE COPY DV