5294 „ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE B N N ONLY
BUILDING PROJECT IDENTIFICATIONPERMIT NUMBER
--iLDING APPLICATION & PER
` ADDRESS BUILDING—ELECTRICAL—PLUMBING—MECHA ICAL
t.,-%
5294
o lL
r PLAN CHECK VALIDATION
I*Y_ "AM OTY.' "�ELECTRICPERMIT fts'h,��.,t '! I°YFEE�*', MAR 2 9 1964
s PHONE
CONTRACTOR'S OUTLETS-SWITCHES-RECEP 500/100
NAME O City of Cupertino
L- O LIGHTING FIXTURES 5.00/1.00 0
CONTRACTOR'S /{1,^ _ PPLIANCES-RESIDENTIAL 4.00 67)
ADDRESS ^
it w PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
Ofl
ENGINEER 3 00
Lie.No. SIGNS TRANS.
ADDRESS ENG* SPECIAL CIRCUIT 5.000 qPEITVALI0wn0
ARCHEss J10
nP EMP.METER OR POLE IN . 15.00
APPLICANT'S MOTORS - CH.
ADDRESS
SERVICE CHANGE 0.00
oz
r M O LICENSED CONTRACTORS DECLARATION �O
¢
<u v I hereby at lirm that 1 am licensed under provisions of Chapter 9 Cay ISSUANCE DATE
m rt w (commencing with Section 7000)of Division 3 of the Business and D BLDG. ELEP, PLG. MECH.
F w z Professions Code nd my license is in full for eq. ❑ ❑ ❑
i D rn— License Class �— Lie.Number.
�j, 1 I l Z Z Z�
o N F w Datc_S C2�—I�`�Contractor ','BU (DING PERMIT
Q f J
¢w 4 OWNER-BUILDER DECLARATION °'3ii!1NFORMA iLON
w 3 LL n I hereby affirm that I am exempt from,the Contractor's License MISC.— REFER TO ORD ygLUATION S/FT.
H LL
04 Law for the following mason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 8.00 Ar7
Cade:Any city or county which requires.permit tocunstroct,alter,
QQQO InIprVVC.dI`mOh]II,OT MPalrllny SlN[NR,prIVr IV Il515NBVIX,aI. FILAWN
.NO. ETEC.
—O u requires the applicant for such permit to the a signed smlcmcnl t el _ TOTA PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's Lice sc
F z i
Law(Chapter 9(commencing with Section 70000of Division3oft e
4 o Business and Professions Code)or that he is exempt Therefrom anUMBING PE MI FEED'
¢ _r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
” , ,Four tame Chun five hundred dollars(550ects the 0)cant lou wnlPenaltyR-DRAIN&VENT-WATER (EA.) 4.00
❑ I,as owner of the properly,or my employees with wages F LOW PROTECT.DEV ICE 2,00 OCC.GROUP RES.UNITS
their slie compensation,will du the work.and the sUlaa m is not
intended or offend for cele(Sec. 7044, Business and professionsINS-FLOOR,ROOF,AR EA,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 workURES-PER TRAP 4.00 sD.PT.FLOOR ASEA roTAL ACSEACE
himself or through his own employees,provided that such improve-
ments are not intended ur offered for sale If,however,the building
ur improvement is sold within one year of completion.the owner. -EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving[but he did not build or im- RES IND CO PB Other
prove for purpose of sale). STRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(See.7044,BusinessN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSOR PARCEL NO.
and Professions Code:The Contractor's License Law does not applyto an owner St'property who builds or improves thereon,and whoN SPRINKLERS-OVER 5 IEA.( 1.00
contracts for such Projects with a con(ractors)Iice"S.dpursntthe Contractor's License Law. ER-SANITAR V-STORM EA.200it/8.00 TRACT NO. PARCEL NO.
ER HEATER W/VENT 4.00
owner Date ER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
L$yo�ltlJiES'C M'B S T�LARATION WATER TREATING EQUIP. 4.00
/ I IItaC[ry�fd lPsm/iRiii. Ila VI'J CRIIIIe'alc afcV D)Cn1 t),ictI-Insure, ZONING ENG.SITE NO.
IX
or it certificate of Workers'Compensation Incur ace,o a certified
Copy Cher«�1 3 _
Policy No.IVw CAn � ��
O O Certifie coPYjs herchy furnished. FIRE SPRINK ENERGY T-24
Z_ z OCerU fila) wit inspection division. MISC.- REFER TO ORD. y ❑ q❑ y ❑ N❑
F' � Apph—no �—
PERMIT ISSUANCE B.00 FLOOD zorvE A.L.0 c.
CC — CERTIFICATE OF Ii XEMPTION FROM WORKERS'
11J >_ COMPENSA'TION INSURANCE: PLG.CONTR. LIC.NO. PLG.
d O ('This section need not be completed if tlm permit is for one TOTAL y❑ N❑ y ❑ N❑
D z hundred dollars IS 100)or less.)
U O I certify that in the performance of the well for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY ¢
LL P slit is issued, I shall not employ any person In any manner so as to
Ow becomcsuhject to tile se WorkeoCompensation Laws ill California, BUILDING
Dale Applicant ALTER OR ADD TO MECH. 4.00
} w NOTICE:TO APPLICANT: IL
alter taking this Certificate of Ex- 4.00 PLAN CHECK
z enlption,you should become subject to the WVrkers'Compensation APPLIANCE
provisions of the Labor Code, you must forthwith comply with FEE
C.) such provisions Or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MCF.M.) 5.00 SEISMIC FEE
I hereby ulfion 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. MICR
3097,Civ.C.l. HEATING UNIT(TO 100,000 B.T.U.) 4.00 M
' I
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTS
Lender's Address
I certify that I Clave read this application and stale Ila,the above VENTILATION FAN (SINGLET 3.00
inhoonation is correct. I agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authori/e representatives'of this city to enter upon the BOILER-COMP (Over IOg000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree m save, Indannify and harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgme s, ost. and expenses which CONST.TAX
Ww,�C_f
.y accrue against City consequence ul'the PERMIT ISSUANCE 3.00
ITTis sa t. MECH.CONT. - LIG NO. MECH.
TOTALTOTAL
Applicant/Contractor Dale
OFFICE COPY