6383APP WNT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
- ILDING PROJECT IDENTIFICATION '• - APPLICATIONSt PERMIT ^^^^
BUILDING
-
BUILDING iELECTRICAL-PLUMBING-MECHANICAL
{l,J� -ljJ }Uj�lJ
ADDRESS
2,0030 Sn=vEtis « ��v�• "
OWNER'ri,
�Nam •' re;• , /' .
VO y� l�/-D0 �7C PHONE,73O'M T
• - -- -
QTY. "' ELECTRIC PERMIT FEE
•'•
PLAN CHECKVALIDATION-
CONTRACTOR-S�D
N ME C,��6. t
OUTLETS- SWITCHES,- R ECEP 5.00/1:00
LIGHTING FIXTURES 5.00/1.00
�•
Ui�.F2/�2 yQ.Q , LIC. ND.''�$ /Z/
-op
UN 2 � 1984
13., zorrioEE OF.4PPLICATION 4
CONTRACTOR'S / .ry/ �J �/ pC
ADDRESS-
�8. 7Z7
APPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT , .'
OR
ENGINEER
LIC. No.
SIGNS 6.00
-JPL -P.C. NO.
-
SIGNS TRANS.- 3.00
AARCH, OR
DDRESS ENG. -
SPECIAL CIRCUIT 'S.00
"' PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
- - .ZIP ' s
1
/
'
APPLICANT'S •" h e -
aDORE6 '. Q'
elGd�T /� / S'9sQ3
MOTORS'•', SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CON TRACTORS DECLARATION
x
I herehy affirm Ihat I am licensed anile. pr*wisions of Chapl tire
(commencing with Section 7000) of Division 3 of the Business :ted'
P,ofesriors COt1v` rid my license is in fall force and effect.
License Class_ G- Lir. Numner �g7/_7y-/-
Bac
` - OWNER-Bu1LDI'I, U-CI.n A1�Ir3N -5/KK,
-
' I hereby affrm that I mn.exonlpt from. the Contractor's License
Law for the following reason. (sec. 7031.5, eusinessand Professions
Code: Any city or county which requires a permit to construct, alter;
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signet) statement that'
Ile is licensed pursuant to the provisions of (lie Contractor's License
SU C 2 ATE .
BIL
�E
❑ .,
PLG. MECH.
❑ ❑
y
; • .•
- ,BUILDING PERMIT
INFORMATION
MIS0.- !, REFER TO ORD
PERMIT ISSUANCE 6.00
VALUATION
��� yp 8/FT. `
ELC. CONTR. - + LIG. NO, •
ELEC.
TOTAL
p R T TO
-
DTV. - PLUMBING PERMIT FEE
Law (Chapter 9(commencingwith Section 7000) IT Division 3oflhe
Business and Professions Code) or that he is exempt therefrom and
STORIES
!�
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant forapem,it subjects lire applicant ton civil penally
.fact more than five hundred dollars 45500).):
-
ALTER -DRAIN -WATER (EA.) 4.00
. ❑ Lias owner of the property, or nhy 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, GOND. 4.00
,intended or offered for sale (Sec: 7044, Business and Professions
Code: 'Fire Contractor's License Low does not apply to an owner of
--
,
FIXTURES - PER TRAP 4.00
SO. FT. FLOOR AREA
- •....•-
TOTAL ACREAGE
,_.
S.
property'who builds or improves thereon, and who does such work
himself car through his own mhiployees, provided that such improve-
mentsaremotintendedoroffered forsale. If, however, lite building
or improvement is sold,within one year of cumpletion, the owner.
ho der will hove III, hanlen of proving that he did not build or int-'
Prove for purpose nfmleJ.
Ci 1, as owner bf lite property, am exclusively contracting with
GAS - EA. SYSTEM -1INC. 4 OUTLETS 4',00
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
.BUILDING USE
'RES `w .CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIALWASTE INTER. 20.00
licensed contractors to construct the project (Sec. 7044, Barites
and Professions Code; The Contractor's License Law does not apply
man owncT ul property who builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
,
ASSESSORSPARCELNO.-
'•
contracts for soc h projects will) a contractions) licensed pursuant to
the Contractor's License Law:
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACTNO,
PARCEL NO.
❑ I and exon,,! lander See.' ,B.&P.C. for this
reason
. , WATER HEATER W/VENT 4.00
owner - Date
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORK PRS'COMPBNSATION DECLARATION
-
I hereby affirm that I have a cerlilicate of consent to self -insure,
or a certificate of Workers Compensation Insurance; or a cenified
copY ttemufls�3HOO La Ky RoyA[..GLoe�
Policy Nn.-V�f� K
ZONING
- .
ENG. SITE NO.
-"/' 41VPee&?OON%. �-/ Ni
`pU� Ce Dn�'1,copy is hereby furnisher
f Ccr11yf� 'upy js� y1 with' tp�mspey'yioJy dJ�(°°n'
AG0llcun/l_/�/ �u /-O F�,L/$C-
FIRE SPRINK
Y❑.• N❑
ENERGY T-]<
YO *NF
MISC. - REFER TO ORD.
' CF'RT]FICATE OF i:x Fm PTION FROM WORKERS'
PERMIT ISSUANCE .5.00
FLOOD ZONE
A.L.U.C.
PLG.CONTFL ` LIC. NO. -
-
1LDT,AL
l I C04ENSATIONINSURANCE,
This "Hot need nut be;completed it the permit is•hhr one
Y❑ NO
❑' N❑
DTY. MECHANICAL PERMIT - FEE
- a
FEE SUMMARY
I undred dollars IS 100) or less.)
1 certify that in the performance of the work for which this per-
mil is issued, 1 shall riot employ any person in any manner so as to
- -
'BUILDING
become subject to the Wmkcam' Compensation Laws of California.
Ume Applicant
NOTICE TO API'LICAN I': If, alter making this Certificate of lix-
emption, ypu should become subject to the Workers' Compensation
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
ilply with
provisions of the I.mbor Code, you most forthwh ant
such provisions or this permit shall be deemed revoked.
QQ
FEE 6Q.. J
AIR HANDLING UNIT ITO 10,000C.F.M.) 3.00 '
AIR HANDLING UNIT (OVER 10=C.F.M.) 5.00
SEISMIC FEE.
o
CONSTRUCTION LENDING AGENCY
I hereby affrin that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work HIT which this permit is issued (Sec.
3097, Ci,,C. ).
MICROFILM, '
HEATING UNIT ITO 100,000 B.T.U.). 4.00
Lenders Name
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC '
Lenders Address
I Pettily Did l have read this application and stale dint the above
VENTILATION FAN (SINGLE) 3.00
information is codecs I agree to comply withi city and cmmty
ordinances and state laws relating'to building construction, and
-PLUMBING
BOILER -COMP(3 H.P. c 100,000 B.T.U.) 4.00
BOILER -COMP (Over 10,0,000 BTU) SEE FEE SCH: '
-
MECHANICAL -
hereby aullr.ria representatives of this city to enter upon -the
above mentioned property for inspection purposes.
MISC. - REFER TO ORD.,'
CONST. TAX
(We) agreeto save, indemnify and keep harrinss,the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
PERMIT ISSUANCE _ 3.00
granting of this nit - r•
4P• -gni
MECH. CONT- LICARI. MECH.
TOTAL " ' .
TOTAL 11So Jc
Signatureo pplicant/Contactor., _Date':•"
Y OFFICECOPY