6687 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY.
;BUILDING PROJECT IDENTIFICATION - PER-MITNUMBER
t ! APPLICATION & PERMIT
• emLmNc '
ADDRESS _ J��fi 6 6 8 7.
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWN 'Sx � - - -- - PLAN CHECK VALIDATION
NA ELECTRIC PERMIT FEE 'D
• PHONE C �x PA
O ACTOR'S
N - UTLETS=SWITCHES:RECEP, 5.00/1.00 ti
2,0 ILIGHTING FIXTURES 5.OD,1.00 - , IuN �j p 1984 .
dooeE•sRS - PPLIANCES-RESIDENTIAL 4.00 J "
G PHONE Z PANELS' . s 5.00 {{ (Ixx,�1�I1�1((��P
•OBFE4PA LICATION
ENINE • SIGNS 6.00 LA CHECK FEE. P.C.NO.
ENGGINEEERR .. ,
ARENG, Lie.No, SIGNS TRANS. 3.00
ADDRESS ss - SPECIAL CIRCUIT '5.00 PERMIT VALI ATION -
zIP TEMP.METER OR POLE INS. 15.00
AooRess Ts MOTORS - SEE FEE SCH. ,
SERVICE CHANGE 10. �SANCE
D¢i 00 IIIYYYIII '
.02 LICENSED CONTRACTORS DECLARATION - I
< U I I hereby affirm that I am licensed Under provisions of Chapter 9 DATE
N rt u (commencing with Section 7000)of Division 3 of the Business and BLDG. EL CT PLG. MECH.
r m Z Professions Code d m license is in full for e
Z o m Licen�s�/f Lic.Number
o m r��a? Dalc(p� CoNrador ❑, ❑ ❑
¢ ¢Is< OWNER-BUILDER DECLARATIO ` BU I ING PERMIT
wo A IN ORMATION
3: LL N I hereby affirm that{am exempt from the Contractor's License MISC.- - - REFER TO ORD
LL o Q Law for the following reason.(Sep.7031.5,B.Smessand Professions - VALVA ON $/FT.
t -
Code:Any city or county which requiresa permit to construct,alter. PERMIT ISSUANCE 6.00
Se Q Q 20 improve,demolish,or repair any structure,prior to its issuance,also ELEC,CONTR. LIC.NO. ,
y X c¢ requires the applicant for such permit to file a signed statement that El
TOTAL O RMIT T
w m w he'is licensed pursuant to lite provisions of the Contractor's License
.F Z Q law(Chapter 9(commencing with Section 7000)of Division 3 of the
4 O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢I- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by am,applicant far a permit subjects the applicant to a civil penalty DRAIN&VENT-WATER E
ALTER-DRAIN of not note than five hundred dollars($5001): ( A•) 4.00 .
❑ I,as owner at the property,of my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole owner of the
will do the work,and the slWil law is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 -
Code:The Contractors License Law does not apply to an owner of
property whgbuilds or improves thereon,mrd who does such work FIXTURES-PER TRAP 4.00 - SO.FT.FLOOR AREA TOTAL ACREAGE '
• himself or through his own employees,provided that such improve. - .
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTL'ETS 4.00
or improvement is sold within one year of completion,the owner-
hailder will have the burden of proving that he did not build or im- IGAS-EA.SYSTEM'-OVER 4 IEA.) 1.00 BUILDING USE
prove for purpose of Said j.' INDUSTRIAL WASTE INTERy RES' IND CON . PB" Our,.
❑ 1,as owner of the property,am .exclusively contracting with 20.00 El
contractors to construct the.project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cade:The Contractor's License Law does not apply
to an Owner of property who builds or improves thereon,and who LAWN SPRINKLERS,-OVER 5(EA.) 1:00 '
contracts for such projncGwdh a contractod s)licensed pursuant to - ,
the Contractor's License Law. SEWER-SANITARY-STORM EA.200f1/6.00 - - TRACT rvo. PARCEL rvo.
❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT - q,00 '
reason
Owner Dute- WATERSYSTEM 4,00 'AcG.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 '
I hereby affirm that 1 have a certificate ofconsensu
I to self-inre,
or a certificate of Workers'Compensation Insurance or a certified ZONING. ENG.SITE NO.
copy thenal'(Sec. 800,Lab.C.l
'
Policy N ]Q3f:�3COmpany _�-U TIS • '
❑ Certified copy is hereby famished , FIRE SPRINK ENERGY T$4
Z
Z ❑ fI, if It cu y is fed with the city i edion division.
E- p7( A 01icunt_L�f�/yUt MISC.- .REFER TO ORD. Y Q, N� Y ❑ N�
cc Cl:RTI P ICAI'F:OF Ii XI:M PTION FROM WORKERS' PERMIT ISSUANCE _6.00 FLOOD ZONE A,L.U.C.
IL COMPENSATION INSURANCE PLG.CONTH. LIC.NO. PLG. Y N Y
d (This section need not he completed if the
+ Z hundred doll D.,($100)or less.) Perntil_is far one TOTAL
U 0 1 certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I'shall not employ any person in any manner so as to
become Subjectto the Workers:Compensation Laws of California.
IS.W Date-Applicant ,BUILDING
} So NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 4.00
♦- 2 s mption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.EM.) 5.00 SEISMIC FEE
I hereby uffinn that there is.a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
file 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
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC
1 certify that I have read this application and state.that the above VENTILATION FAN (SINGLE) 3.00
information n correct I agree to comply building
c city and county BOILER-COMP(3 H.P.or 100,000 B.T.U:) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorise representatives of this city es enter upon the BOILER-COMP(Over 10i BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for' lion purposes.
(We) agree to save, rode y and keep harmless the City of MISC.- REFER TO ORD.
Cupertino Groat liabilitie figments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX -
may I I way ac me Inst said City in consequence of the -
gm pg this per t. MECH.CONT. LIC.NQ MECH.
�yfKu�z TOTAL TOTAL
gnilare of Applicant)Contmctor ate
OFFICE COPY .•