4339 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -.USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 4339
•x ADDRes s
4� ..yyyll�v� BUILDING—ELECTRICAL—PLUMBING —MECHANICAL
\• NAWN
ME S 0V ?7*W& 0, PLAN CHECK VALIDATION
X��Wa/ @ DTV. ELECTRIC PERMIT FEE
I. vMDNE�/ •'
NAMQRACTDR' s OUTLETS-SWITCHES-RECEP " 5.00/1.00
LIC.No. LIGHTING FIXTURES 5.00/1.00
ADRESSTORs
DAPPLIANCES-RESIDENTIAL 4.00
CONTRA
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 60O PLAN CHECK FEE C.N0.
.
OR '
ENGINEER
Llc.No, SIGNS TRANS. 3.00
ADDRESS eras. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00 PAID
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 SEP 211983
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09 LICENSED CONTRACTORS DECLARATION
a u I hereby,affirm that I am licensed under provisions of Chapter 9
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z
(commencing with Section 7000)of Division 3 of the Business and A ¢n B E ECT. PLO. MECH.
H D i Professions Code,and my license is in lull force and effect. ❑ ❑ ❑
o i H D License Class Lin.Number
Uote Contractor
¢ r s BUILDING PERMIT
a o n U OWNER-BUILDIiR DIiCLARA'fION INFORMATION
X ; i_ I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
V, VALUATION $/FT.
Fuya Law for the following reason.(Sec.7071.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter. Qz
z �} ELEC.CONTR. LIQ NO. a
a ¢ G improve,demolish,or repair any structure,prior to issuance,also ELEC.
O u requires the applicant for such permit to file a signed statement that 'TOTAL PER TO
u w$ he is licensed pursuant to the provisions of the Contractor's License
r z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe r7
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE f f O
a r $ the basis for the alleged exemption.Any violation of Section 7031:$ STORIES TYPE CONSTR.
of
any not more than
for ive hundred dollars(h500).)canuoacivilpenalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars the applicant
v
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 2.00 OCC.GROUP RES.UNITS
sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec: 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Low does lot apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR�Aq/EA TOTAL ACREAGE
. mems are not hrough
ownemployees,for
provided ever,hat the
improve GAS-EA.SYSTEM-1 4.00 OG.{/
mems are not intended or offered for sale.IL however,the building ✓O
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- IND CON PB Omer
p v for purpose of So c. INDUSTRIAL WASTE INTER. 20.00
I,as owner of the property,am exclusively contracting with
liceIs ed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00ASSESSORS 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 IEA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/6.00
the Contractor's License Law. TRACT NO, PARCEL NO.
❑ tom exe exec, B.AP.C.for this WATER HEATER W/VENT 4.00
reaso r1
U � ^11 �'I`I'I Owne- WATER SYSTEM 4.00 ACC.GATE ACC.FILE NO.
WORKERS'COMPENSAT'ION DECLARATION WATER TREATING EQUIP, 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified -
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.• REFER TO ORD.
O Applicant Y ❑ N� Y N�
Hy
CfiRTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 - FLOOD ZONE A.L.u.c.
LU
W 2! COMPENSAATION INS
URANCE vLG.CONTR, LIC.NO. PLG.
2 (This section need not be completed it'the permit is for one TOTAL Y EJ NE] Y E] N
hundred dollars($100)or less.)
) O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL h mit is issued,I shall not employ any person in any manner so as to
0 Wbecome subject to the Workers'Compensation Laws of California.
CL Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 371i°%
} W NOTICE TO APPLICANT: IL after making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Lobar Code. you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10.000GEM.) 5.00 SEISMIC FEE
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 permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
Icertify that l 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 100,000 DTVI SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against City in consequence of the
granting sisr MECH.CONT. LIC.NO. MECH,
TOTAL
Signal re of Appl �k
TOTAL G
i a o tmcto Dale
OFFICE COPY 0
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