2331 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PER IT ry
BUILDING APPLICATION & PERMIT ^ 1
ADDRESS 929 3 I
d Town Co BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - - - - - ---
PLAN CHECK VALIDATION
NAME _ OTY. ELECTRIC PERMIT FEE
Patrick T C PHONE 252-8614 1.1
CONTRACTORS - OUTLETS-SWITCHES-RECEP 5.00/1.00
Atlas Furnace CO. LIC.NO,1 80 LIGHTING FIXTURES 5.00/1.00
nooaess DRs APPLIANCES-RESIDENTIAL 4.00 '
1 Commercial St. PHONE 739-05,16_PANELS 5.50 DATE OF APPLICATION
OR
SIGNS 6.00 PLAN CHECK FEE ♦ I P.C.N0,
ENGINEER
LIC.NO, ISIGNS TRANS. 3.00
ARCH,OR ENG, SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
SS
ADDDRESSDRESS
APPLICANT s - MOTORS SEE FEE SCH.
SERVICE CHANGE 11�00'g.00 /�
'02 LICENSED CONTRACTORS DECLARATION �L�aEs
ru 1 hereby affirm that I am licensed under provisions of Chapter 9 _
uAi (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
w < BLDG. ELECT.1. PLG. MECH.
r N z Professions Cod a y license is in full force o I ❑ ❑ ❑ ❑
z o Licens 15 Lic.Number
9 a,,E- w� Date Contractor ,$ It
a x 5 - BUILDING PERMIT
¢ ¢ OWNER-BUILDER DECLARATION
" MISC.- .- RD INFORMATION
X 3: y 1 hereby affirm that 1 am exempt from the Contractor's License
H u o J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE - 6=1
VAINAn
wr Code:Any city or county which requires a permit to const ruct,alter,
M. ¢ s-p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
n w m¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contnmtors License -
za Law(Chapter 9(commencingwith Section 7000)of Division 3 of the
4 O Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
0C the basis for the alleged exemption.Any violation ol-Section 7031.5 STORIES TYPE CONSTR.
u ; _ by any applicant for a permit subjects the applicant ton civil penally gLTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(85007.1:
❑ I,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.
mems are not intended or offered for safe,If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4(EA) 1.00
builder will have the burden of proving that he did not build or im- - . - . BUILDING USE
prove IND CON PB Dtner
prove for purpose ofsale.). 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.8. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The 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 contractm(s)licensed pursuant to
the Contractor's License Low. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACD.FILE No.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of-consent to self-insure,
or a certificate of Workers'Compensation Insurance,ar u certified ZONING ENG.SITE NO.
copy thereof(Sec 3800,Lab.0
Policy Na4.J AM'6mpany FliOinelsl_nd Tnla
0 ❑ Certified copy is hereby furnished.
FIRE SPRINK ENERGY Toa
Z Z ❑ CertifiKdpgopysis witlL tlhe dia.
division. MISC- REF ER TO OR D.
O Applicant^^�+�A••PPzl (:B S2 _ Y ❑ ry❑ y ❑ N❑
~'rnPERMIT ISSUANCE
Lu CIiRTIFICATIi OF EXEMPTION FROM WORKWORKERS' FLooD ZONE A.L.u.c.
W COMPF-
eeNSATION INSLJRANC17 PLG.CONTR. LIC.NO. PLG,
6.00
1 O (This section mad not be completed If the permit Is for one TOTAL Y❑ NJ[] y ❑ N❑
Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,1 shall not employ any person in any manner so as to
0 w become subject to the Workers'Compensation Laws of California
Date Applicant BUILDING
m ALTER OR ADD TO MECH. 4.00
} en 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 nrus't'fnrlhwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=11F.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(OVER l OQ000 B.T.U.)7.50
Lender's Address-' . 7.50 .ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
information n correct I agree to comply with all city and county - BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
oNiwnces and state laws relating to building l city and
co and
above-coeby authorize ropertyforins inspection
this city ID enter upon the BOILER-COMP Was,100,000BTU)SEEFEESCH. MECHANICAL Q S�
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino ugainst liabilities, judgments, casts a I - hses which PERMIT ISSUANCE 3,00 CONST.TAX
troy in any way accrue against said City in c I a q nice of the
granting of this permi MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
,Signaler DI'Applicant/Contractor Vale 1 10.50
OFFICE COPY -