6528 'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -,USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING
APPLICATION & PERMIT 6528
I / ADDRESS -
BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
-NER'S PLAN CHECK VALIDATION
11 HAUS ELECTRIC PERMIT FEE PAID
AVE
TRACTOPS UTLETS-SWITCHES-'RECEP 5.00/1.00 MAY 2 5 1984
IC HD.I LIGHTING FIXTURES 5.00/1.00
CONTRACTCONTRACTORM APPLIANCES 00
4.
ADDRESS ( City of Cupertino
vHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT - SIGNS 600 PLAN CHECK FEE P.C.NO.
OR
ENGIN
LIC.No. SIGNS TRANS. 3.00
AARCH.ON DDRESS AY. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zIP TEMP.METER OR POLE,INS. 15.00 -
APPLICANTS MOTORS SEE FEE SCH. 1
ADDRESS -
SERVICE CHANGE 10.00
to o LICENSED CON'L'RACTORS DECLARATION O / 0 "
IF v 1 hereby affirm That 1 am licensed under provisions of ChaPter 9 C✓ p ISSUANCE DATE
y i Icommencin with SC'nion 70X0)of Divimo 3 of the Business anJ
a g 0 B DG. ELECT. PL❑G. MECH.
F N i 1'rofessiom Coley licence:is in Cull if of
z o m — License Clay` Lic.Number- _
aY Dale_Snu-& Contractor_ _ — p
¢ ¢ a OWNER-BUILDER DECLARATION BUILDING PERMIT
¢too INFORMATION
Law I hemy arm am exempt Oren tntrac
hffithat I he Cotorslcensc
' L ' MISC.— ., REFER TO ORD
04 Law for the lbllowing reason.(Sec.7031.5,Bushiest and Professions pERMIT ISSUANCE 600 -VALUATION ' S/FT.
Cale Any city or county which requiresa permit toconstrucr alter,
5a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
—DLL requires the applicant for such permit to File a signed statement that TOTAL PERMIT TO -
w he is licensed pursuant to the provisions of the Contractor's License y
iii Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe / }0�
— a Business and Professions Code)or that he is exem}H therefrom and CITY. PLUMBING PERMIT FEE
T= the basis for the alleged exemption.Any violation of Section 7031.5 !STORIES T PE CONSTR.
a � by any applicant Cor a permit objects the applicant too civil penally - ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than Five hundred dollars(S5001J:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP ES.UNIIS
their sate compensation,will do the work,and the structure is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4',00 . Q
Code:The Coutraelon s License Law does not apply to an owner of
nrperty who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 Sa FT.FL R AREA TD L ACA GE
-msdf or through his own employees,provided that such improve- - /)
menti are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 4.00 �� !l//.
r.improvement is wild within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 7,00 BUILDING U E
budder will have the burden al'proving that he did not build or ire- RES IND COH P Omar
prove for purpose ofsalc.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply ,
to in owner of prolurty who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
enntmas forsuch projects with a contractor(s)licensed pursuant to
the Con tractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under See. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Dam WATER SYSTEM 4.00 ACCO E ACC.ELLE NO.
WORKI!RS'CO.+IPENSATIONDI[CLARATION WATER TREATING EQUIP, 4.00 1
�J 1 herebyalfrm that I have n cert iflcate of consent to sd Ginsuru, - - ZONING ENG.SITE NO.
/ or a certil ica c of Workeri CampcnsaRon Insurance,or a cerUficd
copy thereof(Sec.3800,Lxb.C.).
Policy No. Company
O' Cl Certilkdcopyifherebyfurnished. FIRE SPRINK ENERGY LR4
Z Z ❑ Certified copy is Filed with the city impeetion division. MISC.- REFER TO ORD.
O Applicant _ Y ❑ N❑ Y ❑ N❑
Q N CER'I'IFICA'I'EOP IiXBMPTION PROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE AL.0 c.
'W > COMPENSATION INSURANCE. PLG.CONTE. LIC.NO. PLG.
D' 0 ('Phis snmirin need not be con,deted'a the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z) Z hundred dollen IS 100)or lova.)
U O 1 certify that in the performance of the work for which this per- Y. MECHANICAL PERMIT FEE FEE SUMMARY
LL I— mit is issued,I shall not employ any person in any manna so es to
0 w become su.n,J�et I eN'orkcrs' Ip 12. fCa omia.
a NUII1jc��iypplicant_�r ALTER OR ADD TO MECH. 4.00 BUILDING,
} to NOTI f(J APPLICANT: If,a mr ma ung the Ccrt ifir of Ex-
F Z_ emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Later Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.NL) 3.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 5.00 SEISMIC FEE
I hereby affirm that.there is a Construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the pe,fammnce of the work for which this permit is issued`Sec: MICROFILM
3097,CN.C.). HEATING UNIT(TO 1D0,DD0 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address - - ELECTRIC
I,;eIUffythm 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
il�rrmaUan is comet. I agree o comply with all city and county PLUMBING
dinanev's and state laws relating to building construction, andBOILER-COt913 H.P.Or 100,000 B.T.U.) 4.00
: bv_aWhoriae representatives of this city to enter upon the BOILER-COMP P (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
alrogve-me nuoned property for inspection purposes.
(We) agree to save, indemnify and keep hermlcss the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs end expenses which PERMIT ISSUANCE g-00 CONST.TAX
may in any way accrue against sad City in consequence of the
grunti g0 hi �^l. MECH.CONT.. LIC.NO. MECH.
OCH. TOTAL
Signa are at A 1/Contractor Date
OFFICE COPY ' -- /�