5433APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE,PALL POINT PEN ONLY
BUILDSNG PROJECT IDENTI FIC.5Krrj
APPLICATION & PERMIT
ILDING— ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
5433
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PLAN CHECK VALIDATION
DATE OF APPLICATION
PLAN CHECK FEE P.C. NO.
CONTRACTOR SES-RECEP
"
UTLETS -SWITCH5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACT 's
nppRESs ��� FHON
ARCHITECT
OR
ENGINEER
LIC. NO.
JAPPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
SIGNS 500
SIGNS TRANS. 3.00
ARCH.OR ENG,
ADDRESS
SPECIALCIRCUIT 5,00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
ZIP
/ P
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APPLICANS
T
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Businessand
Professions Code 4ad y 'cense is in lull (or f
«
License I Li c. Number
BLDG. ELECT. I PLG. MECH.
❑ ❑ ❑
Dater`
- Contractor
see, OUIL'DINGiPERMIT o
;.y?t„F, j'• �,°jNFORM_ ATIO_N, ..
WNER BUILDER DE LARA ON
I hereby affirm that I am exempt from the Contractors License
Law lot the lullowing reason. (Sec. 7031.5. Business and Professions
Code: Any city or county which requires3 permit to construct, aIle,.
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Cha trr9fcommencin with Section 70001o(Division3ofthe
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
MISC. — REFER TO ORD
ygLUATION
S/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO. ELIC.
TOTAL
PERMIT TO
Jj
T Lu� B�� G
z.dtl'?i,t�' tiQ„yW .a +F$: yak,
GTY rs(:'1°gPL'UMBING P_E_RMIT H�}Y {M��y��yyx,t,FtEE
aJ fs+� s -`P 'ihX- sF,T1 wiK xtrf✓Jv2
STORIES
TYPE LONSTR.
by any applicant ort permit subjects the applicant to a civil penalty
of not more than live hundred dollars 155001.1:
ALTER-DRAIN&V T -WA ER(EA.)4.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for .IS (Sec. 7044, Business and Professions
BACK FLOW PROTECT. DEVICE 2,00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 4.00 4 7—
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
SO. FT. FLOOR AREA
TOTAL ACREAGE
FIXTURES - PER TRAP 4.00
himself or through his own employees, provided that such improve-
ments a re not intended or offered for sale. If, however, the building
.�
GAS - EA. SYSTEM-11NC.40UTLETS 4.0
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
licensed contractors to construct the project (Sec. 7044, Business
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB Other
❑ ❑ Cl ❑ ❑
INDUSTRIALWASTE INTER. 20.00
LAWN SPR INKLERS -I INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
and Professions Code: The Contractor's License Law does not apply
to an owner of Property who builds or improves thereon. and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER lI Q:MT 4.00
❑ lam exempt under Sec.—, EL&P.C. for this
reason
Owner Date
1,
WATER SYSTEM 4.00 T
ACC.OATE
ACO. FILE NO.
WORKERS'COMPENSATION DECLARATION
WATER TREATING 101ld 00
I hereby affirm that I have a certificate of consent to sell' -insure,
or a certificate of Workers Compensation insurance. or a certified
/�' �� u�7 ���
¢ONING
ENG. SITE ND.
e copy Ihereof (Sec. 3900, Lab.C. I.y/ _yam
Policy No. Company /f>�JJ_Az1W,0
❑ Ce lifted copy ishereby Fruished.'3,40re3v 2
�Certi t is Iled' itl he cit inspection division.
PPiiIt 44can
APR 131984
FIRESPRINK
y❑ N❑
ENERGY T-24
y❑ N❑
MISC.- EF RTO ORD,
CERTIFIG\ OF F.l 'MPI'ION FROM WORKERS'
PERMIT ISSUANC 6.00
FL00o ZONE
A.L.U.C.
PLG. CONTR. LIC. NO. PLG.
TOTAL Q.
COMPENSATION INSURANCE
ITIox section need not be completed if the permit is for one
hundred dollars IS 100) or less.)
I certify that in the performance of the work for which this er
p
mit is issue) I shall not employ any person in any manner So as to
becmne subject to the Workers'Compensation Laws of California
Date \pplicant
NOTICE. TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Worker' Compensation
provisions of the Labor Code, you most forthwith comply with
such provisions ur this permit shall be deemed revoked.
Y C] NE]
Y ❑ N❑
>`r'W3" +tiv.t yF'i{,r''.}'ss a +/bs "tti:^7L!r�iTPs: t^ P USgs's
nl H' rY ;jS FEE
CITY',? MECHANICAL PERMIT, Tk
a2 a °xu�?stk:1-s{ ).-=,ei.'? 3l.v.
-
4i° ��9
KAt FEE -SUMMARY,
g.,x'c
L
BUILDING
I ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10MOC.F.M.) 3.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
I hereby alfirm that Ohre is a construction lending agency for
the perf°rmunce of the work for which this permit is issued ISce.
1097, Civ.C.).
HEATING UNIT ITO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.17.50
ELECTRIC
Lender's Name
Leader's Address
I certlly that have Lad this application and State that the Above
iniormation is camel. 1 agree to comply with all city and county
uNinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
CQ 0 p�
BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
BOILER -COMP Over 100,000 BTUI SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned Property for inspection purposes.
IWe) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, lad cots. costsand expenses which
mu sin any w accrue aga St id City in corse,. once of the
gr ling sl t r 1.
/ �3
r G
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3,00
MECH. CONT. UC. NO.
MECH.
TDTAL
$'
'' TOIT�L
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Ignut urs I , plCanl/ O ractor ato%:
OFFICE COPY