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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ALY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING —ELECTRICAL— PLUMBING —MECHANICAL
PERMIT NUMBER
^
b
BUILDING
ADORES
OWN LC/_ r1 L /-r�/S'O r,/
NA
HGNE
.. a .'„ x, .. 0/,k.,
OTV: -` ''-ELECTRIC :IPERMIT._'
PLAN CHECK VALIDATION
PAID
16 1984
APR
.�{p -
OAIY AQATION
CONTRACTORS
NAME'A iZ326Q
NyCT,CKD,
OUTLETS -SWITCHES - RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CADORES ) ONTRACTORS LAPPLIANCES-RESIDENTIAL
3b j V(� ViPHONE�LS -I b2
- 4,00
PANELS 5.00
ARCHITECT
OR S,, ar'el
ENGINEER JJ �1
' uc. uo. -
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH, OR ENG.
ADDRESS
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
ITEMP. METER OR POLE INS. 15.00
' ZIP
A
ADDDRESSDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
'
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Cade, andAry license is in full for no efte
License Class— Number' d'
ISS CE TE
BLDG. ELECT. LG MECH.
❑ ❑ ❑
_ Con
Dale Contractor
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Code:Law Any citylowing ounly on.chreg03sa permit tocnd Professions
Code: Any city or county which requirese permit to construct,, also
improve, demolish, L of repair any 9watofi prior n its issuance, also
lu ole a Cont statement i that
requires the applicant fir Such provisions of the )ofDreision License
he is licensed pursuant to the with
Law (Chapterand Pr (commencing Or Section is exempt
Business and Professions Code) or [hal he is exempt therefrom and
pt the of om and
the basis for [be alleged exemption. Any violation of Section 70315
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).):
'4 �BUILyOING�P
INFORMN RMIT
-llO
MISC.— REFER TO ORD
PERMIT ISSUANCE 6.00
VALUATION S/FT.
ELEC. LONTR, I LIC. NO. TOTAL
TOTAL
QTY. kl"y 1°"!P,LUMBING P,,ERMIT AN
TR. �, - `' ` • - RAN
�N +, +. 777* . 4 b A I
RMIT TO
'
STORIES
T PE CONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 4.00
❑ 1, as owner of the property, or my employees with wagesas
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4,00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 4,00
GAS - EA. SYSTEM -1INC. 4 OUTLETS 4,00
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments are not intended or oo'cred for sale If, however, the building
SQ FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose ofsale.).
I, as owner of the property, an exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
E MD CON PB Omer
El 1:1 11
El❑
INDUSTRIALWASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5A0
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
licensed contractors to construct it,, project (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply
to an owner of property who builds or improves thereon, and who
ASSESSORS PARCEL NO.
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor, License Law. -
❑ lam exempt under Sec. ,B.&P.C. for tllis
reason
SEWER -SANITARY -STORM EA. 200ft/6.00
RACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM 4.00
ACC. GATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKERS'COMITNSATION DECLARATION
1 hereby affirm that I have a ceNifnTte of co _
or a curtificam of rkers' Compensation Ins
ZONING
ENG. SITE NO.
copy iher
1.
Pop n n n
I.W= iir 5
.�.
verified copy is hereby furnished.
ertifi i N d oh the city inspection division.
App many
MISC.- REFER TO ORD.
FIRE SPRINK
v� N�
ENERGY RP4
V[] N[]
CERTIFICATE OF I iXEMPTIJN FROM WORKERS'
COM%iNSAI'ION INSURANCE:
(This section need no[ he Completed if the permit is for one
fit)
PERMIT ISSUANCE 6.00 cry
FLOOD ZONE
Y [:] N
A.LU.C.
Y 0 N 0
PLG. CONTR. LIC. NO. PLG.
TOTAL
hundred dollars l$ 100) or loss)
1 certify that in the performance of the work for which this per
mit Is Issued, 1 shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of Cxlifoima.
Date Applicunt -
pp +q e� rv,,
UTVT f(n ^rry NVIIIIECHANICAL�PERMIT '1' wf 1 F E
.K n e { y,.-,
I -
I9; FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 4 G01
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 4.00
AIR HANDLING UNIT (TO lO=C.F.M,) 3.00
PLAN CHECK
FEE
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT(OVER 10,000QRM.) 5.00
SEISMIC FEE
CONS'T'RUCTION LENDING AGENCY -
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.CJ. -
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address - -
HEATING UNIT (OVER 100,000 B.T.U.P.50
ELECTRIC
I certify that 1 have read this application andstale that the above
information is correct. I agree to comply with all City and rountg
ordinances and state haws, relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
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 IOver t00,0008TU15EE FEE SCH.
MECHANICAL
(Wc) agree to save, indemnify and keep h:,.IcSs the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said'City in consequence of the
PERMIT ISSUANCE 3.00
CONST. TAX -
grant =,R. �—
f���(f�//'J I —•psi
man LT
MECH. CONT. LIC. NO.
MECH.
TOTAL
r TO-,TAL'
14 0
Signature of Apphcanl/Conlmelor Date
OFFICE COPY