3872 APPLICANT TO FILL IN INFO MATIOM WITHIN,RED LINES - USE BALI. POINT PEN ONLY
t '
BU I LDING PROJECT I DENTI FICAT PERMIr,NumeER q
ADDRESS _ ;S'7tUF.JS. ckzrrC APPLICATION & P.ER. �S I Z
AOORE55 '/ �1 / '
BUILDING-ELECTRICAL-PLUMBING -MECHANICA
OWNER'sLAN CHECK VALIDATION
NAME y'i �J,� 1 , - QTY. ELECTRIC PERMIT FEE
V/ l '�IC N//f/rJ 17 f PHONE
CONTRACTOR 4 q NAOUTLETS-SWITCHES-RECEP 5:00/1-,00
ME)) CTS ,�1 /I ..••''
- ( /r� N N✓�. LIC'NO.*�( LIGHTING FIXTURES, 5.00/1.00
C,ONTRAC70R'S APPLIANCES-RESIDENTIAL • 4.00 _
AALD 0RE 5 / �y`'�Y�/i
L'� U�I�F(�-S� N`• PHONE/�l'F3,;L0 =PANELS, 5.00 0 DATE OF APPLICATION
AHCHnECi - SIGNS .6,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER _
L¢.NO. - SIGNS TRANS. 3.00
ARC OR ENG. " SPECIAL CIRCUIT '5,00 PERMIT VALIDATION
ZIP. - EMP.METER OR POLE INS. 15.00 - PAID
APPucANrs - • MOTORS �j SEE FEE SCH.
AogREss UNI�LM-S/ l y �✓'� ,r SERVICE CHANGE I 10.00 JUL J• 953
ro O E LICENSED CONTRACTORS DECLARATION '7
p CIt NC Cupertino
a u O I hereby affirm that 1 ons licensed under n 3 of the
of Chapter 9 - 1S6d ANCE DATE
w or y (commencing with Section 70001 of Division 3 ohhe Ousiness anti _ - .BLOC. EL T. PLG. MECH.
E. D z Professions Cod and my licensees in full force' fkcLf - ❑ - ❑
z D� - License Class Lic.Number dd``-- - ❑"
2 7. F Date�_!_L_�9_Contractor v
S, ¢ ¢ r`t DOWWNNERR-BUILDER DIzCLARA'PION � - B ILDING PERMIT
ac rc W o - " INFORMATION
w ;a. y ' I hereby of Jinn that I am exempt from the Contractor License MISC.- REFER TO ORD
Fu0or Law fordo following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 �, VALUATION $a /FT.
u-` Code:Any city or county which requires permit to constnsl,alter, -
¢.0 improve,demolish,or repair,any structure,prinr,4h its issuance,Also ELEC.CONTR. LIC.pNO9. / ELEC. S
a
D¢ "requires the applicant for such permit to file a signed statement that �O P/b �,�p TOTAL PERMIT TO'
w m he Is licensed pursuant to the with Secti of tire 0cDivContractor's License
rzi Law(Chang 9(commenCeder)Or UnitionbexeofD ivision3ofthe
.a
Business and Professions Codel or that to is exempt therefrom and QTY. - - PLUMBING PERMIT FEE
li-$ the basis for the alleged,exemption.Any'violation of Section 7031.5 STORIES TYPE CONSTR.
byany applicantfor a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
oF
f not ora than file hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with'wages as BACK FLOW PRO,TECT.•DEV ICE 2,00 OCC'GROUP 'RES.UNITS
their sole compensation,will do tire work,and.the structure is not - ..
intended or offered for sale (See 7044,-Buiiness and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:*1 lie Contractor's License Low flocs not apply to an owner of -
propertywhobuildsorimprovesthereon,and'who doessuch work FIXTURES-PER.TRAP 4.00. SO,FT.FLOOR AREA TOTALACREAGE
himselforThrough or offered forssprovidedthatsuch insProve- -
mentsarenotirRendedoroffereoyees, lrovided that Such
the building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement will have
is sold'within one year of completion:did io t the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or ins-. RES IND or PB Omer
Prove for purpose ol'sale.).- INDUSTRIAL WASTE INTER. 20.00
❑ d as owner of the property.he reject(Se . 7044.tBu with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS"-1 INC 5 V.B. '5.00 ASSESSo s AHCEL NO.
and Professions Code: ty Conbuildsro Licensest h duesnotapply. - _ '
Wont owner of property who builds t r improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 9.00 '
contracts for such projects with a Contraclor(il licensed pursuant to -
thcContramor'sLiccnseLaw, SEWER-SANITARY-STORM EA.200ft/8.00 ' TRACT No. PARCEL No.
❑ l wn exempt under Sec. ' .R,&P.C.for this WATER'HEATER W/VENT 4.00
mason -Data Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO. I'
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 >' _
I hereby affirm (hat I have a certificlde of consent Us lhlrnurc, _
or a certificate of Workers'Compensation Insurance,or a certified ZONING „ENG.SITE NO.
copy thereof(Sec.3800,Lob.C.).,
Policy No: Comp:my
O \❑�Certified copy is hereby furnished. FIRE SPRINK ENERGY T.24
Z Z /y�Certihcd y Is fled h sty inspection div'wian. - -
O Applicant MISC:.- ' REFER TO ORD, v ❑ N,❑ v ❑. .;N❑
X N CERTIFICATE is
I VN'IPTI FROM WORKERS' "PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCI? PLG.CONTR. LIC.NO. PLG.
1i 1 ('['his section need not be,completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
D Z hundred dollars(5100)or less.) - -
U'O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I shall not employ any person in any manner so as to
U becom.,.1reettothe Workers'Compensation Laws of California.
LU Date Applicant - ALTER OR ADD TO MECH. 4,00 BUILDING
„} W NOTICE: TO APPLICANT: If,alter making this Certificate of iT
F 2 emption,you should become subject to the Workers Compensation APPLIANCE' 4.00 PLAN CHECK .
provisions of the Labor Cade, you must forthwith coinply with FEE
U such provisions or this permit slot[be deemed revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 3.00 h
CONSTRUCTION LIiNDINC AGENCY AIR HANDLING UNIT(OVER 10,000C.FM.) 5.00 ' SEISMIC-FEE -
' 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(See. MICROFILM''
3097,Civ CJ. HEATING UNIT(T0100,000 B.T.LL) 4.00
Lender's Name HEATING UNIT(OVER l00,000B.T.U.)7.50 ELECTRIC D Sn
Lender's Address - r
'I certify Nat I have read thi,ti,mieation and stole that the:move VENTILATION FAN (SINGLE) 3.00 -
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, 'anti BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to tinter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE$CH. -MECHANICAL -
above-me ntioned property for inspection purposes.
(We).agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. -
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
nlay in" Y way ;u.c - o ainst stud City in mnsttlumtce or the PERMIT ISSUANCE 3.00
grant this permitrt � MECH.CONT. LIC.NO. MECH.
T( TOTAL
TDTAL TOTAL Q,S�
e 'AppliclatiCcontratelm Dula.
OFFICE COPY -