5926 APPLICANT TO FILL IN INFORMATION WITHIN RED TINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATIONPERMIT NUMBER
a4DnDIrvG APPLICATION & PERMIT" A .
ooREss
�® Q VI•$ '�, I BUILDING —'ELECTRICAL-PLUMBING —MECHANICAL ` 59,26 ,
OWNER'S
41
NAMEPLAN CHECK VALIDATION �
1 PHONE
Z�2a{p$ GTY ELECTRIC PERMIT FEE
CONTRacroRs F
NAME _ OUTLETS-SWITCHES-RECEP 5.00/1.00 PAID
uc.No. LIGHTING FIXTURES 5.00/1.00
ADDRESS
APPLIANCES"-RESIDENTIAL 4.00 - AUG 2-4 '1984
E55
PHONE PANELS 5.00 DATE OF APPLICATION
ogcHlTecT, - SIGNS 6.00 P JJH(�fl�.i�fje�) !)P.c.NO.
ENGINEER __r
uc.NO. SIGNS TRANS. 3.00 -
aRCH.OR ENG.
ADDRESS ,,// SPECIAL CIRCUIT � S.00 PERMIT VALIDATION
' V, Vr. zIP 1�fY EMP.METER OR POLE INS. • 15.00
AP ucgrvrs - SEE FEE SCH.
ADDRESS - MOTORS '
SERVICE CHANGE •10.00
' 02 LICENSED CONTRACTORS DECLARATION
¢ hereby affirm that I am licensed under provisionsof Chaplet 9 ISSUANCE PATE
(commencing with Section]000)of Division 3 of the BusmeSxomP `
F,w z, Professions Code,and my license is in full force and effect. BLDG. ELECT. PLG. MECH.
2 O.v,— License Class - Lie.Number ElEJ.� ❑
4,Z„r w ; Dare Contractor
Q yJ
¢ ¢w u OWNER-BUILDER DECLARATION / BUILDING PERMIT
X 3 a-H I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD INFORMATION
r u O j Law for file
following reason.(Sec.703 L5,Business and Professions PERMIT ISSUANCE VALUATION' S/FT.
Code:Any city or sou R which requiresa permit toconstruct,alteq 6.00
R R Q O improve,Demolish,or repair any a ucfure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o¢ requires the aPPlicant(or such permit to file a signed statement that TOTAL �•
u w m y he is licensed Pursuant to the provisions of the Contrncfoi s License PERMIT TO
ra: Q Law(Chaprer9(cosiFaS-ngwith Section 7000)ofDivision3of the -�
f x O Business and Professions Code)or.that he use therefrom and DTV. PLUMBING PERMIT FEE ,—
'¢
E.m the basis for
ahe alleged exemption Any violation of Section 7031.5 RIESe., -•TYPE CO STH
ai— by any applicant for a Permit subjects the applicant toacivil penalty ALTER-DRAIN oI
not mom than five It d.d'dollars($500)) IEA.) 4,00
❑ I,as owner of the property,or my employees witb'wagcs as BACK FLOW PROTECT. DEVICE 2,00
Their Sole compensation,will do the work,and [he structure is nal OCC.GROU TES: NI
intended or offereJ for sale(Sec. 7044, Business and Professions DRAINS-FLOOR;HOOF,AREA,CON D. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds is improves thereon,and who does such work FIXTURES-PER TRAP - 4.00 SO.FT.FLOOR AREA TOTALACREAGE V
himself or through his own employees;provided that such such
ove-
mentsare not intended'oroffered for sale.If,however,the building GAS-EA.SYSTEM-I INC:4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- °
buil er will have"Fe
burden of Proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 1,00 BUILDING USE
�- •prn for purpose of sale.): ES IND CON. O OtOber
. {Jr.—�s�owner of the property, in exclusively contracting with INDUSTRIAL WASTE INTER. 20.00
li�.fnsed Contractors to construct the project(Sec..7044,Business LAWN SPRINKLE RS-1 INC 5 V.B. 5.00 -ASSESSogs PARCEL NO.
and Professions Code:'fhe 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 contracloAs)licensed pursuant to
the Contractor's License law." SEWER-SANITARY=STORM EA.200ft/8.00 - TRACT NO. PARCEL NO.
❑ lam exempt under Sec. .&l'.C.for this WATER HEATER W/VENT 4.00
reason
'Owner at WATER SYSTEM. 4.00
ACC.DATE ACC.FILE NO.
.WORKERS'COMPENSATION DECL'RATION WATER TREATING EQUIP, 4.00 ! _
1 hereby affirm that I have a certificate of consent to self-insure, - -
or'a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy(hereof(Sec.3800,f.ab.C.).
Policy No, Company -
O "❑ Certified copy is hereby furnished.
Z Z ❑ ,Certified copy is filed.wilh the city inspection division. - FIRESPRINK ENERGYT"24
P: O Applicant - MISC.- REFER TO ORD. v O N❑ v O NO
CC y CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE; 6.00 FLOODZONE A:L.O.C.
LU COMPENSATION INSURANCE PLG.CONTE. LIC.No. PLG.
d O (This section need no['be completed if the permit is for one TOTAL Y O 'N Y NO
Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manners,as to
O W become subject to the Workers'Compensation Laws of Califomia.
a
Date.Applicant ALTER OR ADD TOMECH. 4.00 BUILDING
} So NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z, emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
'provisions of the Labor.Code, you must forthwith comply with
U.. such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1000041F.M. FEE
) 3.00
. CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 101000C.EM.) 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 '
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I 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'.
ordinances and state laws relating to.building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives,of.this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over loDp00 BTUI SEE FEE SCH. MECHANICAL
(We) agree to Save, indemnify and keep formless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
Inlay i any way accru"SS.id in conseq encs ofthe PERMIT ISSUANCE 3,00
gra gofthis ofitMECH.CONT. LIG NO. MECHrorALTOTAL %�pplicant/ to
Y
OFFICE COPY