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APF . aNT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
L JILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
-
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
5536
Suit'L)
.°DREas
O D _A_ C
OWNER'S
"AME
z PREP, PRDNE.:'.�:
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RI P,ERMI7 EE
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PLAN CHECK VALIDATION
PAID
JUN 2 9 1984
4.
Ci y{{,���� ff�1f{1 CC����ff��pp�Tj{�rt
DATEOFIRVAI041DO
CONTRACTORS
NAME
tiz LV LIC.No. i0 0
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
C.ONTRACTOR's
ADOREu T II 5`
In �j 0 ,L k x ` PRONE 1� IV
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
ARCRITECT
OR
ENGINEER
ua No.
SIGNS 6.00
PLANCHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENG.
ADDRESS
vP
'5.00
SPECIAL CIRCUIT
PERMIT VALID 110N
P
I'
` 1
'\'(VATE
EMP. METER OR POLE INS. 15.00
ADDRESS
ADDRESS
MOTORS SEE FEE SDH.
SERVICE CHANGE 10.00
0260 Lie
n`�'
1\n\
U/
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code nLi is in full force dref�er� O
LicerueC ss Lia Nu.It J
1
BLDG. ELECT. P G. MECH.
❑ ❑
Dale Contractor
I}ING T, s
OWNER -BUILDER DECLARATION
MISC. - REFER TO ORD
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec.7031-5, Businessland ProfessionsPER
Code: Any city or county which requiresa permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance. also
.requires the applicant for such permit to file a signed statement that
he 4 jimmied pursuant to the provisions of the Contractor's License
`
VALUATION S/FT.
MIT ISSUANCE 600
ELEC. GDNTR. LIC. NO. ELEC.
TOTAL
PERMIT TO
i L 1 :i, -E MI •r1
i{
Law (Chapter 9(commeneingwith Section 7000)of Division 3 afthe
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of5ection 7031.5
STORIES
1YPE CONSTR.
by any applicant for a permit subjects the applicant too civil penalty
of not more than five handled dollars ($500).):
ALTER -DRAIN& VENT -WATER (EA.) 4.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractors License Low does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such lmprova
ments are not intended or olfemd for sale. If, however, the building
FIXTURES- PER TRAP 4.00
sa FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SVSTEM-1 4.00 �0
or improvement is sold within one year of completion, the owner-
In will have the burden of proving that he did not build or int-
prove for purpose ofsale.).
❑ 1, as owner of the property, am exclusively contracting with
- . . , ,
GAS EASYSTEM -OVER 4 IEA) 700 00
BUILDING USE
REB IND NG NG PB Other
❑ ❑ ❑ ❑
INDUSTfl IAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.1 1,00
ASSESSOR PA CEL NO.
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License law does not apply
to an owner of property who builds or improves thereon, and who
contracts for such projects with a contraclods) licensed pursuant to
the Contractors License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00 -O O
TRACT No.
PARCEL NO.
❑ lam exempt under Sec.-, B.&P.C+ for this
reason
WATER HEATERW/VENT 4.00 400
Owner Date
WATER SYSTEM 4.00 , 00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate ofconsent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certifiedZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab.C.). 2+ r
Policy No. Company /, f. A L' �$ 1V IS
FIRE SPRINK
Y ❑ N❑
ENERGY U74
Y ❑ N❑
JO Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.
Applicant
MISC- REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.c.
PLG, CONTR. LIC. NO.
TPLG
OTAL �ap?,D�
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
v❑ N❑
v❑ N❑
'ascii .�i4f' e 1fi'r' � '�a�tW
�q) '- `0"' `'b 'w
QTY: >,y--'�]'`a- MECHANICAL P,ERMITn FEE s
4v
s,Y.+ °^ "v"-h'3s''t
i ri»•+>SUMI A:-•ara7A
n y FEEISUMMARY:(I
h c r`f.�.,-•,.:.•,�
BUILDING
hundred dollars fE100)or less.)
1 certify that in the performance of the work for which this per.
mil is issued, I shall not employ' any person in any manner so as todWYtc
become subject to the Workers' Compensation Laws of California.
Date ApNicautALTER
OR ADD TO MECH. 4.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex
emption, you should become subject to the Workers' Compensation
APPLIANCE 4.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10MC.F.M.) 3.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the
e3097, OvC,'nce of the work for which this permit is issued (Sec.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATI NG UNIT 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address -
1 certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and slate laws relating to building construction, and
VENTILATION FAN (SINGLET 3.00
PLUMBING
i f
130ILER-CAMP(3 H.P.or 100,000B.T.U.) 4.00
BOILER -COMP (Over 100,GDOBTU)SEE FEESCH.
MECHANICAL
hereby authorize representatives of this city m enter upon the
ehove-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO. MECH.
TOTAL
w
TOTAL`
j „�
I 9
gra ling of this permit t
6` 2Y' '
Ignature of Ap icanl/Contractor
OFFICE COPY