4965 �y APPL ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATPERMIT NUMBER
9ILDIN1 1 0 APPLICATION & PER 4965
t[ IDUDRESf 1 I�
r-
KO OL �WL.L %Jz BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
J4965
u NAME CITY. ELECTRIC PERMIT FEE PLAIN CHECK VALIDATION
k• .1t sRONE PAID
Zip CONTRACTORS �^ UTLETS-SWITCHES-RECEP 5.00/1.00
ucN LIGHTING FIXTURES 5.00/1.00 MAY 2 51984
CONTR CTO 'S
ADDREss �O� PPLIANCES-RESIDENTIAL - 4,00 yl.]� Cf Cupertino
- '1t Ci l"11L r [%k C�k ..E 727-3()65 PANELS 5.00 CI DATE OF APPLICATION
s%z q �•M'r�r PLAN CHECK PEE P.C.NO,
OR D .. SIGNS 8.00
ENGINEER D
LIC.NO. SIGNS TRANS. 3.00
nooa ESS SPECIAL CIRCUIT 5.00
1 I PERMIT VALIDATION
D / S�e zm Z EMP.METER OR POLE INS. 15.00
APPLICANT DRES 'S
o AOORFssMOTORS SEE FEE SCH. �2
SERV ICE CHANGE 10.00
Foo
LICENSED CONTRACTORS DECLARATION
\Q U U I hereby affirm that 12M licensed under provisions aprer 9 ISSUANCE DATE
w (commencing with Section 70001 of Division 3 of c Bminess and
r E,i Professions Cod• nd my licence is in full force' J of c BLD ELECT. PLG. MECH.
License Cl' Lie Number
O y "?' Du1t�Conlmct r
El El
a Y f J
¢ c w ¢ OWNER-BUILDIiR UEC A N ! BUILDING PERMIT
a o a D INFORMATION
m g LL y I hereby affirm ilia, 1 am exempt from ih cense MISC.- REFER TO ORD
r ._ o a Law for the following rtasan.(Sec.7031.5,Nosiness and Pfofssloos PERMIT ISSUANCE VALUATION SIFT.
Cade:Any city orcounty which requires a Permit to construct,alter. B'�
rta,¢ improve,demolish,or repair any'structure,prior to its ionancc,also ELEC.CONTR. LIC.NO. ELEC. /�lD ✓V O
o C requires the applicant forsueh permit to file a signed statement that TOTAL PERMIT TO
RE
he is licensed pursuant to the provisions of the Contmetor's Limns
Fii Law(Chapter 9(commencingwill,Scetion 7000)a'Division 3u f Dle N/
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE VE7�1 $Iile
¢ = the basis for the alleged exemption.Any violation of Scctian 7031.$ STORIES PE CONSTR.
u by any apdie,nl for a permit subjects the applieont to civil penalty
of not more than five hundred dollars 13500.) ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ 1,as owner of the PfoPert Y,or my ant ployces with wages is BACK FLOW PROTECT. DEVICE 2,00 OCC.GROUP .RES.UNITS
their sale compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AR EA,CON D. 4.00
Code The Contractor's License Law dots not apply to in owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 sO.ET FLOOR AREA TOTAL ACREAGE
.
himself or Put intended
his own In,,d fors provided evLarch improve-
dling -
orimprmnotinicndedwithinoncyeaaloILhowetion the theo Jing GAS-EA.SYSTEM-11NC.4OUTLETS 4.00 /GOO
or improvement wicm have
is e b within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 66 BUILDING USE
builder will have the burners of Proving that Ice did not build or ice- REB IND C PB Orae,
pane for purpose of the.l. INDUSTRIAL WASTE INTER. 20,00
❑ 1,as owner of the property,he exclusively cool 4, ing with ❑ ❑ ❑ ❑
and Professions
contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSO PARCEL no.
and Professions Code:The Contractor's o Licence Law does
eon not apply
conn owner ofpropertys with
buildsorimproves thereon,and who LAWN SPRINKLERS-OVER 5IEA.1 1.00 3�6con _
the trach for such
ceneILwithacontradomllicensed Pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 1r'
the Contractor's License Law. TRACT N0. PARCEL n0.
❑ lam cxmnpt under Sec. ,B.RP.C.,itr this WATER HEATER W/VENT 4.00
reason
DUZI, uw'ner WATER SYSTEM 4.00 ACC,DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certifteve of convent to self-insure.
or a certiflcate of Workers'Campct ration 1 sennet,u u c,rtif,d ZONING ENG.SITE NO.
copy thereoflScc.3S00,Lub.C.l. y, � r
Policy No. CampauY -[JIB /V
U ❑ Cetificd copy is hcfchy hth
ZZ ❑ CertillCRmv 's fled vtlh t �' insLRctiun division. FlRE$PRINK ENERGY T44
F.gam Applicant_ - MISC.- REFER TO ORD. y ❑ N❑ v ❑ N❑
CC to CERTIFIOSTF:OP Ii\E.s1PTl M WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LO > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the Permit is for ane TOTAL Y❑ N❑ Y ❑ N❑
D 2 hundred dollurs(S 100)or less.)
U O 1 certify that in the performance of the work for which this Per- CITY. MECHANICAL PERMIT FEE
,LL I- mit is issued,I shalfrot employ any Person in any manner so as to FEE SUMMARY
U become subject to the Workers'Compensation Laws of California. Qy
U C. Date Appli.al ALTER OR ADD TO MECH. q,p0 BUILDING
} W NOTICE 'I'O AI'I'LICA N'I': IL after making this Ccrt ifcwc of Its-
2 comawn,you should become subject m the Workeri Compensation
APPLIANCE 4.00 PLAN CHECK
Provisions of the Labur Code, you must forthwith comply with FEE
U such provisions or this pemnit shall he deemed revoked AIR HANDLING UNIT(TO 10,100 OF.NL) 3.00
CONSTRUCTION I.IiNDING AGENCY AIR HANDLING UNIT(OVER 10=11F.M.) 5.00 SEISMIC FEE � _4
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this pemtit is rTed(Sec. MICROFILM
3097.CivC.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's AddreHEATI NG UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC
ss
I certify that I have read this application and stow that the uhove VENTILATION FAN (SINGLE) 3.00
lomnances ^s estate. agree to comely with all city uunitcti county BOILER-OOfxR(3 HY-ch-100,000B.T.U.) 4.00 PLUMBING
ordinances and state laws relating c to building construction. and
hereby outhorize representatives of this city to enter upon the BOILER-COMP (Oser lW,DDOBTUISEEFEESCH. MECHANICAL
ahuve-mentioned property for inspection purposes.
(We) agate to save, indenmify and keep hurnI the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs send expenses which CONST.TAX f �Q(� N
may in any way aces a inn vin City in con vlsee ec of the PERMIT ISSUANCE 3.00
g IL MECH.CONT. LIC.NO. MECH.
-- ,l � TOTAL TOTAL 3 9
Signature of Applicant,'ontmctor D tc
OFFICE COPY