4374APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
97 A
LF J I �F
4374
BUILDING
ADDRESS y
SO•• S,hd,` N agl
• UVINn'a
AME
QTY. ELECTRIC PERMIT FEE
PLAN CHECK T N
�o,-civet C PRDNEss-2 -_711i 41
SEP 2 {,
6 1983
CONTRACTORS -
NAME
OUTLETS - SWITCHES -RECEP 5.00/1.00
p
O Pili Lt.. NO. 3l It
'
City Of Cupertino
LIGHTING FIXTURES 5.00/1.00
r,ONTRAcronsAPPLIANCES
- RESIDENTIAL 4.00
3 X. 'HONE 1G'•
PANELS 5.00
DATE OF APPLICATION
ARCHITECTSIGN$
on
ENGINEER
LIC. NO.
6.DD
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH, OR ENG,
ADDRESS
ZIP
SPECIALCIRCUIT 5.00
PEYATE
EMP. METER OR POLE INS. 15.00APPLICANTS
SsSERVICE
MOTORS SEE FEE SCH,.ADDRE
CHANGE 10.00LICENSED
CONTRACTORS DECLARATIONI
hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 70001 of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Class Lie. Number 3vim;= i&=
p�
B G. ELECT. PLG. MECH.
❑ ❑ ❑
Dh[e _ Contraclor
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
I hereby affirm ing I am exempt from the Coumador's License
Law for the followingreason. (Sec.uires a,Businessand Professions
Code: Any city or county which squirese permit to construct, alter,
improve, demolish, or repair any structure, prior n its issuance, also
requires ilicensed
nedp pursuant
cIC IS IILCnS{:d r11fS11B11t t0 [Ile jl[OVlslnll$ of the Contractor's I.icesllC
t t such revisit ID Elle a Signed StatNenc rise
Law (Chapter 9 (commencing with Section 7000) of Division 3 of lire
Business and Professions Cade) or that he is exempl therefrom and
MISC.- REFER TO ORD
PERMIT ISSUANCE 6.00
VALUATION
WID r
$/FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
i
D
-
QTY. PLUMBING PERMIT FEE
- B�T0 ES
V C TR.
the basis for the alleged exemption. Any violation of Sect ion 7031.5
by any applicant fora permit subjects the applicant to a civil penalty
of not more than five hundred dollars 15500).1:
�f"(`vLv� 1571
ALTER -DRAIN & VENT -WATER IEA.) 4.00
❑ h as owner of the property, or my employees with wages as
their sole con'pensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2,00
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractors License Law docs not apply to an owner of
FIXTURES - PER TRAP 4.00
SQ FT. FLOOR AREA
TOTAL ACREAO
,
Property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
merits are not intended or offered for sale. If, however, the building
- GAS-EA.SYSTEM-11NC.40UTLETS 4,00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that be did not build or im-
Prove for puvposeofsaie.).
❑ -1, as owner of the property, am exclusively comructing with
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
E IND CON Pe Omer
❑ ❑ 0 ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
licensed contractors to construct tiro project (Sec, 7044, Business
and Professions Cndc: The Contractor's License Law does not amply
to an owner of properly who builds or improves thereon. and who
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts forsuch projects with a contractor(s) licen,ed Pursuant to
the Contractor's License Law..
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ lam cxnnpt under See ,B.&P.C. ti'r this
reason
WATER HEATER W/VENT 4.00
Date Owner
WATER SYSTEM - 4.00
ACC.DATE
ACC. FILE NO,
WATER TREATING EQUIP. 4.00
WORK ERS'COMPENSA'IION DECLARATION
I hereby affirm that 1 have acertificate of consent to sell' -Insure,
or a cendicale of Workers' Con'pe"sation Insurance, or a ce}r ifiad
copy thereof (Sec. 100, Lab ,C.).� ���1
-
ZONING
ENG. SITE NO,
Poll cy No. C7 mPany 1`6141
. ertified copy is hereby Numbed
Certified Copy is led -��yJ1 hh the Iy )fispection division.
Applicant_.i:a,�,_�j� (YRQ A�w.�t�
MISC.- REFER TO ORD.
FIRE SPRINK
Y N
ENERGY T 24
Y ❑ No
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A. L. U.C.
COMPENSATION INSURANCE
(This section need not he completed if the Permit is for one
PLG. CONTR. LIC. NO.
PLG.
TOTAL
Y N
v N
hundred dollars C$100) or less.)
1 certify that in the performance ol'the work for which this per-
mil is issued, 1 shall not employ any person in any manner so as to
CITY MECHANICAL PERMIT - FEE
FEE SUMMARY
BUILDING
a
10
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE '10 APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10PMC.F.M.) 3.00
PLAN CHECK
FEE
emption, you should become subject to the Workers Compensation
provisions of the Labor Cade, you Hurst forthwith comply with
such provisions or this permit shall he deemed revoked.
AIR HANDLING UNIT (OVER 10)000C.EM.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
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.
3097, Civ.C.).
-
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
HEATI NG UNIT (OV ER 100,000 B.T.U.)7.50
ELECTRIC
I certify that l haverced lhisapplication and stale that the above
VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county
ordinances and slate laws relating to building cmo uciion, and
PLUMBING
BOILER-COMP(3 H. P. Or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby aull'oritc representatives of this city to enter upon the
above-mentioned Property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs ande0xpenses which
may in any way accrue against said City in consequence of 'e
granting of this permit,
c2�
MISC. - REFER TO ORD.
PERMIT ISSUANCE 3.001CONST.
TAX
MECH. CONT. LIC. NO,
-
MECH.
OTAL
TOTAL
OO
S'gnams of ppani/Contractor U in
OFFICE COPY