5049 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMIT NUMBER
aDILpING _ APPLICATION & PERMIT 5049
A a o 00 /U/o/ N
�1�t�0 Nepark Mall (�L / BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
ONW..NER'S N 2^y .'v i 1 1: - T p ��' e' P LAN CHECK VALIDATION
Vlen aTe ei"laVings 793-7456 OT�'•'I ":ELECTRIC,PERMIT,„,'_; ;'FEES
PHONE /, - �.h. .v •n
• 1 coNTRAaons UTLETS-SWITCHES-RECEP 15.00I7.00
"S"E&p M Sprinkler Corp.LlCNO 261708 LIGHTING FIXTURES 5.00/1.00
Apyry^7Toss1y'l,,l/xVB.'C
PPLIANCES-RESIDENTIAL 4.00
Re w;D It CA PHON368-3393 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER 3.00
L.C.No. SIGNS TRANS.
ARDR. ENG. PERMIT VALIDATION
ADORESS ss SPECIAL CIRCUIT .
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION 1T �•
cu I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w<w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG, MECH.
D i Professions Cod�1 y license is in full �9ag AbfSet, ❑ ❑ ❑
Z, o N Littnse CIe 'C'e Num El
9 Y F� Date Conlrecto
E a w u OWNER-BUILDER DECLARATION tr `s. BUILDING PERMIT+::
REFER TO ORD `x'=; ;,dt-INFORMATION
X
m N 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- /VALUATION S/FT.
' F u o< L sa,for the following season.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00 - /6 7 O•f�.•d
-' Code:Any city or county which requiresa permit to construct,alter.
re C < G improve,demolish,or repair any structure,prior to its issuance,also ELEL.CONTR. LIC NO. ELEL. C r�rY /
OIL requires the applicant for such permit to file a signed statement that TOTAL JC r PE$MIT TO
e. w m u he is licensed pursuant ro the provisions Of the Contractor's License 457
l '�
i Law(Chapter 9(commencing with Section 7000)of Division 3 of the "^ z- + '. . -I ,. Ge /�
5 i Rosineu and Professions Code)cr that he is exempt therefrom and DTV.'-'"' - PLUMBING PERMIT':
1- the basis for the alleged exemption.Any violation of Section 7031.5 ` lJJ VV VV IEB TYPE CONSTR.
by any applicant for a permit subjects the applicant tDacivil penalty AL TER-DRAIN&VENT-WATER IEA.) 4.00
of not more than five hundred dollars(S50D).):
❑ I.as owner of the property,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. 71344, 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 does such work FIXTURES-PER TRAP 4.00 sir.FT.FLOOR AREA TOTAL ACREAGE
�,�• himself or through his own employees,provided that such improve.
menu are not intended or offered for sale.If,however.the budding GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or . .00 improvement is sold within one year of completion,the owner GAS-EASYSTEM-OVER 4 (EA.) 1Bu1Lo1rvG USE
builder will have the burden of proving that he did not build or ire- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with El ❑ C1 1:1 1:1
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cade: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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY•STORM EA.200f1/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. .B.SP.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKF.RS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00
I hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy lherenG1Y62 O'Lab.( enith Insurance
Policy No.f�LL �L�,CC'ompan
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z JD(Certi(ied copy is filed with the city inspection division. MISC.- REFER TO ORD. Y❑ N❑ y ❑ N❑
O Applicant
HCERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU - COMPENSATION INSURANCE PLG.corvrR. LIC.No. PLG.
a O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
p+' Z hundreddollarsfS100)orless.)
U O 1 certify that in the performance of the work for which this per- FEE SUMMARY
LL f mit is issued.I shall not employ any person in any manner so as to CITY. MECHANICAL PERMIT - / f•-�
O W become subject to the Workers''Compensmion Laws of Culifurma. BUILDING ( Z 13 "�
Date Applicant ALTER OR ADD TO MECH. 4.00 --•
} y NOTICE TO APPLICANT: If,after making this Certificate of Ex-
L•- ? creation,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK 3 �,
provisions of the Labor Code, you must forthwith comply with FEE O �-
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10AOOC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=0GF.M.) 5.00 SEISMIC FEE
I hereby affirm that 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.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NO UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
• - - Information is correct I agree to comply with all city"and county PLUMBING
s ordinances and state laws relating to building construction, and BOILER-ClUIv1P(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino t liabilities,judgments, costs and expenses which PERMIT ISSUANCE 300P
CONST.TAX
° may in wry accrue agair�t s City in consequence Of the
1 granti ft er l MECH.CONT. LTL.NO. NEC ,C !`.`,•�K.,a"�S,.I , s/
0,6/25/84TOTAL '~TOTAL", ". 0�� -
I S t o pp' ant/Contract Date
)� OFFICE COPY
Ic ;
s _