4929 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BUILDINPERMIT NUMBERG PRO
BUILDING L�APPLICATION & PERMIT A �L1ng
ADDRESS
BUILDING — ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME [ pp. QTY. ELECTRIC PERMIT FEE
AMk $4,RF h At Q— PHONE 0 �
JW
NAMERACTORs OUTLETS-SWITCHES-RECEP 5.00/1.00 PAID
Q'V YA G G Lie no. '07 ro4 LIGHTING FIXTURES 5.00/1.00
CONTR
ES kDRs APPLIANCES-RESIDENTIAL 4.00
DREJAN 2 6 1964
O
S+7 141004. U E ^9 PANELS 5.00 � � DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHEOIEIf6EOf Ur+®
ENGINEER ll�+ l77 MF��
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 75.00 ^,/
AMOTORS ENT'ACSEE FEE SCH.
ADDDRESSDRESS
SERVICE CHANGE 10.00 1
Mari
o LICENSED CONTRACTORS DECLARATION
Fi W I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
¢ w (commencing with Section 7000)of Division 3 of the Busiaessand BLDG. ELECT. PLG. MECH.
H w z Professions Code and my license is in full forcg a ef'ec Q./ ❑ ❑ ❑
Z, z w W License Class Lie.Number .9 �f-
Date — Contracsor_O/i ry YN HIR<7�
A, y f BUILDING PERMIT
W a w u OWNER-BUILDER DECLARATION INFORMATION
w1 hereby affirm tile( I am exempt front the Contruchn'S License MISC.— REFER TO ORD
H : OJ Law forthe following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6 VALUATION $/FT.
sw> s Code:Anycity.,county which requires a permit to construct,alter,
ac improve,demolish,or repair any structure,prior to its P,S,me,UIS. ELEQ CONTR. LIC.NG. ELE .
caa o a requires the applicant for such permit to file a signed statement that TO AL PERMIT TO
n w$m he is licensed pursuant to the provisions of the Contractors License +
HZ > Law(Chapter 9(commencingwith Section 7000)of Division 3 oftbc
E i o Business and Professions Code)or that he isexempt therefrom and QTY. PLUMBING PERMIT FEE
Ie t- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR,
a by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars 0500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00 OCC.GROUP RES.UNITS
their 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 Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve-
mentsare not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner. GAS EASYSTEM-OVER 4 (EA) 100 BUILDING USE
builder will have the burden of proving that he did not build or int - . . .
- IND CON PB Oma,
prove for purpose or sale.). INDUSTRIAL WASTE INTER. 20.00
El 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contracmrs to construct the project ISec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cod,The Contractor's License Law does not apply
to an owner of property who builds or inmroves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with it contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200f[/5.00
the Contractors License Law. TRACT NO, PARCEL NO.
❑ ]Ana exempt under Sec..,IS&RC.for this WATER HEATER W/VENT 4,00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ER$'CONIPENSATION D17CLARATION WATER TREATING EQUIP. 4.00
1 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.).
PolicyNo. Company '
O ❑ 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 ❑ IN E] Y ❑ No
� LO CERTIFICATE OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLDDDZONE A.L.U,C.
LLI > COMPENSATION INSURANCE PLC,CONTR. LIC.NO. PLG,
0. Z( This section need not be completed if the permit Is for one TOTAL Y❑ N❑ ❑ N❑
Y
hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- DTV MECHANICAL PERMIT FEE FEE SUMMARY
U_ H unit is issued, I shall not employ any person in any manner so as In
O W heco c^ j•cl o beWorkers'C pensati m Laws of C 1 tbn ia.
IS. Date Applicant VIM" 5/A�t10 LT L^. AL OR ADD TO MECH. 4.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of F,
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 FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 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 H EATI NG UN IT 100,000 B.T.U.)7.50 1&0 ,,ej0
Lender's Address ELECTRIC x
Icertify that l have read this application and slate that file above VENTILATION FAN (SINGLEI 3.00
information is correct. I agree to comply with WI city and count)' BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCR. 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 Slid City in consequence of the
grunting tins permit. MECH.CONT. LIC.NO. MECH.
/^ TOTAL TOTAL
S afore of pliant Conlmcto Datc +
OFFICE COPY