1237 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY V !
BUI LOI NG PROJECT I DENTI FICATI ON PE MI NEJM ER
BUILDING AIS. APPLICATION & PERMIT _ _ 123 7
AGGRESS /�. �� ,
1 (/ L BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
NAME RS \ (a-hI Myl J y' t PERA'.
fn,/( �r/f} T/J TV; 1 $ELECTRIC PERMIT
e"'1 1 PHONE - •,
. conTRAc*ons UTLETS-SWITCHES-RECEP 5.00I1.00
NA �
-;5r W3 LIGHTING FIXTURES 5.00/1.00
ADDONS RESR's PPLIANCES-RESIDENTIAL 4.00
CONTRACTOR
(J 'y/
PHONE // /y PANELS 5.00 a DATE OF APPLICATION
ARCHITECT6DD PLAN CHECK FEEP.C.NO.
oA SIGNS .
ENGINEEn
Sec.no. SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ADDRESS 19
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 - �y//
o O o LICENSED CONTRACTORS DECLARATION /�^i� 'd`
a
to U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w < i (commencing with Section 7000)of Division 3 of the Businessand BLDG. ELECT. PLG. MECH.
H N i Professions Code.and my license is in full force qd effec ❑ ❑ ❑
z o ,� License Clair f'/n Lie.Number ry
Q z r w Date /d' -2Y-V/ Contractor s OCT 2 U 1981
Q W < OWNER-BUILDER DECLARATION .y�{y: z'INFORMATION'_'
w 3 0 N I hereby collo that I am exempt from the inesuacmr's License MISC.-
REFER TO ORD ^k 'Y'FT.
o ¢ CLaw ode:Any
citylorcount Son.cSec-703LS,Bmimssand Professions PERMIT ISS 6.00 VALUATION s/FT.
� w'nom Cade:Anymolish.ountywhiny structurep prior
t oconstruct,
uancafter,
u, x< p 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
w $N he is licensed pursuant to the provisions of the Contractor's License r-
sir Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe {{ / w'• """+k'A fi' & s, @ ' ���-
a: Busineu and Professions Code)or that he is exempt therefrom and QTY- 3' PLUMBING.PERMIT _ FLEE''
0;1— the basis forthealleged exemption.Anyviolation of Section7031.5 .=+-.re STORIES TYPE CONSTR.
i3 - by any applicant fora permit dollars theapplicanttoacivil penalty ALTER-DRAIN -WATER IEA.) 4.00
of net mothan five hundred dollars(55001.1O).):
❑ 1,as owner of the property or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for Sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve- GAS-EA.SYSTEM-11NC.40UTLET$ 4.00
yrbuildingonenes are not intended or offered for sale.If.however.the
.cr improvement is sold within one year of completion, 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 im- RES IND CON PB Omer
prove 1,as owner
INDUSTRIAL WASTE INTER. 20.00 ❑ 0 ❑ ❑ 0
❑ d as owner of the property,he exclusively contracting with
licensed contractor,: construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to ancontracts
owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
the Contractor's
ontract sir Licenects LwithacontmnoHsl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Conlmclor s License Law.
❑ l am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC,DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate oftonsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.l.
Policy No. Company
O ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T.24
Z Z V Certified co is Rlep,wi tb py inspection division.
Applicant 7S,t u- fes, E =c . MISC.- REFER TO ORD. Y C] N C] Y E] N0
cc �/ PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
� CERTI FIC TE OF EXEMPTION FROM WORKERS'
UJ - COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y N� YO N�
CL O (This Section need not be completed if the permit is for one TOTAL
U Z hundred dollars IS IOD)or less.) E',c
V O I certify that in the performance of the work for which this per f^„' ,!" �Yw < 't" t r'�SII+x'FEE SUMMARY ,q,
IL F mit is issued,I shall not employ any person in any mannerw as to QTY. 'MECHANICAL PERMIT r . FEE' ,
ti
U become subject to the Workers'Compensation Laws of Czlifamia.
y
Date ApplicantALTER OR ADD TO MECH. 4.00 •y BUILDING
} w NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10X0C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
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.). I HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 "
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00
Y _ercby authorize representatives of this city to enter upon the 801LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
_ above-mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, casts and ex erases which CONST.TAX
x. may in any way racem",;*d City in consequence of the PERMIT ISSUANCE 3.00
granting thuper MECH.CONT. LIC.NO. MECH,TOTAL/as S Signa[ AppUarc
'*,'} OFFICE COPY