2251 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT P ;(t LY 03=10496
BUILDING PROJECT I DENTIFICATI ON ///' PERMITNUMBER
BUILDING p APPLICATION & PERMIT 2 251
ADDRESS 0435 R Tantau d4.00 BUILDING-ELECTRICAL-PLUMBING-MECHANICALOWNERS F el 1 1PLAN CHECK VALIDATION
"AMEQTY. ELECTRIC PERMIT FEE7J Ampex PNpNE255-4800 'NAMERAcroRsUTLETS-SWITCHES-RECEP ORVIN E GINEERING-IC.ND.01076 LIGHTING FIXTURES ADDRESSCONTRACSanta C1ara,CA PPLIANCES-RESIDENTIAL3271 Kifer (i PHONE 73 -219 PANELS DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR SIGNS
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADRENG.
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLIC
AOGRESS MOTORS SEE FEE SCH. `iUJ•
OGRESS
Sv
LICENSED CONTRACTORS DECLARATION SERVICE CHANGE 10.00
Woo
¢ is u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y< A. (commencing with Section 7000)of Division 3 of the Business and BLD ELECT.. PLG. MECH.
o In Professions Code,and y cense is in full for e t ❑ ❑ ❑
0NZ C{�i�l�`fTl -
i In 0 License Class Lic.Number
,e H w Dale 7/27/82. _Contractor
s BUILDING PERMIT"-
W OWNER-BUILDER DECLARATION -i"q INFORMATION}.:�Ft.-��<•
A.a I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION SOFT.
IL04 Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00
N0 Code:Any city orcountywhich requires apermit toconstruct.alter, $2 667 .00
e A FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR, LIC.NO. ELEC.
o u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m $ he is licensed pursuant to the provisions of the Contractor's License
>m Law(Cha ter 9(commencin with Section 7000)of Division 3 ofthe - "`' - +' ;`h ." n,•+"
a Business and Professions Code) that he it therefrom OTY. �y.' .-PLUMBING PERMIT j•., "'FEE-
ire Sprinkler WO k
C or s exemperem an
ac ==,h ,p" 'j r _ STORIES TYPE CONSTR.
¢H the basis for the alleged exemption.Any applicant
t to action 703L5 - r .. .+i - •. _ --•
by any ea,,thnlfora permit subjects SSOO).licanttoecivil penalty ALTER-DRAIN -WATER (EA.)`4.00
of not more then five hundred dollars(5500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business Bad Professions
DRAINS FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractors License Law does not apply to an owner of
property who builds or improves(hereon,and who does such work FIXTURES-PER TRAP 4.00 S0.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-1 TS 4,00
ments arc not intended or offered for Mile.If,however.the building
or improvement is sold within one year of completion,the owner- GAS•EA.SYSTEM-OVER 4 IEA. F1. 0 BUILDING USE
s builder will have the burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER} ; 20.
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPR INKLERS-1 INC 5 V.Bs x5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply'
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.)
contracts for such projects with a contractor(s)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM E [/5.00 TRACT NO. PARCEL NO.
❑ lemexemptunder See. ,B.&P.C.for this WATER HEATER W/VENT .00
reason
Date _Owner WATER SYSTEM 4.00 ACC.GATE ACC.FILE NO.
WORK F-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy Ihereof(Sce.3800,Lah.Q.
Policy No. Compan I
1^.' eY-Uanita
❑ Certified copy is hereby turn ishppssLL�� FIRE SPR INK ENERGY T-24
Z Z ❑ Certified copy is riled with BIbNCII
F O Applicant MISC.• REFER TO ORD. Y ❑ N❑ Y ❑ No
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 PL000 ZONE A.L.U.C.
LLI � COMPENSATIONINSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
CL a( This section need not be completed if the permit is for one TOTAL
hundred dollars(S 1001 nr less.)
U O 1 certify that in the performance of the work for which this perDTV. - MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,1 shall not employ any person in any manner so us to
L]
U become subject to the Workers Compensation Laws of California. BUILDING
y Date Applicant ALTER OR ADD TO MECH. 4.00 38.50
} us 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 FEE 2rj 03
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 14000C.EM.) 5.00 SEISMIC FEE .50
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. MICROFILM
3097,Civ,C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name Nene
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree lD comply with all city and count, PLUMBING
ordinances and state laws relating to building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this-city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(Wel agree to save, indemnif)' and ep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgmen costs and expenses which CONST.TAX
May in grey way accrue against try in consequence of the PERMIT ISSUANCE 3.00
gran Co a this pe MECH.CONT. LIC.NO. MECH.
7 27 82 TOTAL TOTAL. 64.03
Sig reo Applicant/ c tra Date
James W. McGr ,or, V.P. OFFICE COPY