3268 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-- USE'BALL POI N ONLY
BU I LDING PROJECT I IDENTIFICATION (,ALK
PERMIT NUMBE
BUILDING xN APPLICATION & PERMIT 26'8
DREss v
BUILDING -ELECTRICAL-PLUMBING-MECHANIC
OWNER S - - PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE -
°"°NE PAID
CONTRACTOR UTLETS-SWITCHES-RECEP 5.00/1.00 v �
NAME
LiC.No. LIGHTING FIXTURES 5.00/1.00 _Zn
CONTRACTOR'S 2 PPLIANCES-RESIDENTIAL 4.00 eb MAY 251983 -
ADDREss - '
PHONE PANELS 5.00 . o T OF APP (CATION
_ eF In P.C.NO.
ARCHITECT
OR .S-IGN.S` - 6,Q0 D
ENGINEER
' LIC.No. •' SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
2IP EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 Z3 /�7
waz /
F
02 LICENSED CONTRACTORS DECLARATION r.
rt v U I hereby affirm that I am licensed under p,ovisiooe of Chapter 9 ISSUANCE DATE
h< w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F y z Professions Code,and my license is in full force and effect ❑- ❑ '❑ ❑
zo m - License Class Lie.Number
-
E, z H Date ContruclOr
a y f BUILDING PERMIT
SE u OWNER-BUILDER DECLHUN - INFORMATION
n y I hereby affirm that I ane exempt ROD tlm Comrnctor's Licensi• MISC.- .; REFER TO ORD
H u o j Law for tile PERMIT ISSUANCE 6
e following reason.(Sec.7031.5,Busiuessand Professions _ VALU p0 $/FT.
Code:Any eityor county whichrequiresupernnittocom(ructulter, .00 .L
rt ¢Q p improve,demolish,nr repoir any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. / �O
- o BE requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A w m he is licensed pursuant to the provisions of the Contrlxtor s License
Hzi Low(Chapter 9(commencing with Section 7000)of Division 3 of the s^.
a Business and Professions Code)or that he is exemp''hcmfmm and QTY. - PLUMBING PERMIT FEE E/N '�-
P i O STORIES TYPECONSTR.-
H the basis for the alleged exemption.Any violation of Section malty
n ; $ by any applicant for apenreddosubjects $500).licam toacivilpenalty ALTER-DRAIN. -WATER (EA.) 4.00
of not more than foo the rdollars 15500).1:
❑ Las owner ol'hc willdproperty,ti ur my. n d (lies with re is nos BACK FLOW PROTECT. DEVICE 2.00 OCC CROUP BEs.UNITS
their sole compensation,will(S the work.and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
CodeThe Contractor's Lieanse Law docs not apply to an owner of
propary who builds or improves thereon,and whn docs such work FIXTURES-PER TRAP 4.00 sD.Fr.FLooR AREA TorAL ACRBACE
himself re through his own employees,provided that such improve-
mints are throngot intended Own
emot ployees
provided
ed thathoweve
the building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of cunlpletion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder,will have the burden of proving that he did not buildor int- ,RES IND CON PB Olhe,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
O Las owner of the property,ant exclusively contracting with
Vice
nsed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
•art no
fessions Code:The Contractor's License Law dues not apply
yto an owner of property'who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.), 1.00 3/
contracts lir such projects with a LTmtructons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO PA cELNO.
the Contractor's License Law.
❑ lam exempt under Sec. •BAP.C,for this WATER HEATER W/VENT 4.00
MVO
Dww ownar. - WATER SYSTEM ,4.00 Acc.DATE ACC,FILE NO,
9'ORR13R5'CO.vPI-.NSA'2 Dr:CLAR.\'I'10N WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsent to sell-insure; - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy lhereof(Sec.3800,LaDCA
Pnlicy No. Company ,
Q ❑ Ccrtilicd copy is hmcby furnish¢d, FIRE SPRINK ENERGY T 24 ,
Z 2 ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
Applicant Y ❑ N❑•. Y ❑ N❑
F' - , PERMIT ISSUANCE - 6.00 FLOOD ZONE A.L.O.C.
Cr - CFR'I'IFICA'I'E OI'RXI'MMION FROM WORKERS'
LU > CO.,IPI NSATION INSURANCE PLG.CONTR. LIC.NO.-' PLG.
CL O I'1'his section need nut be completed if the permit is fir one _ TOTAL Y❑ N❑ Y❑ N❑
Z hundreddollars IS 100)or less'.)
U O 1 certify that in the performance of the work for which'his per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL )7 mil is issued, I shall not employ any person in any manner so as to
0 become subject to the Workers'Connpensat ion Laws of California. . BUILDING /Q 0-0
Dec Applicam ALTER OR ADD TO MECH. 4.00
} N NOTICE 'DO APPLICANT: If,after making this Certificate of Ex-
F, Z eruption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
previsions of the Labor Code, you nand forthwith conrplY will) FEE -
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10XDC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMICFEE '_s-0.
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(SCC. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.I 4.00 -
Lender's Name HEATI NG UNIT(OV ER 100,000 B.T:U.)7.50 ELECTRIC rP�SL eh
Lender's Address '
I certify that I have read this application and sone that the above VENTILATION FAN (SINGLE) - 3.00
intbromtioo is correct I 'agree to comply with all city and ULuIYBOILER-COMP13 H.P.Or 100000 BTU) 400 PLUMBING
ordinances and state laws relating to building construction. and , . . . .
hereby entlmriec representatives moves ect this oily to corer upon the BOILER-COMP'(Over 100,000 BTU(SEE FEE SCH. MECHANICAL
above-mentinncd property for inspection purposes. -
(We) agree to wvc, indemnify and keep bvnnlns the City Of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, 'osis and expenses which PERMIT ISSUANCE _ 3.00 CONST.TAX
may in any way accrue against•said C'y in consequencepr the
granting of this pCrllit MECH.CONT. LIC.-N0. MECH.
OT"` TOTAL
SilloomprenI A,plieant/Cnn ract5rV Dat '
t OFFICE COPY