3131 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN O
P T
BUILDING PROJECT IDENTIFICATION MBER BUILDINGAPPLICATION & PERMIT
ADDRESS
oo BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 3131
OWNER
�( "AME QTY. -ELECTRIC PERMIT =FEE
Arty �- .� -b- .
4 ,y PHONE
croRs
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
NAME //�
Q rJ Llc x f LIGHTING FIXTURES 5.00/1.00
CONTRACTOR APP LI ANC ES-RESIDENTIAL 4.00
AOOREss ^J
S9 PHONE f�/ PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 600 iiLANCHECK FEE P.C.NO,
OR
ENGIMf !tip LIC.No. / / SIGNS TRANS. 3.00
ARCH.OR ENO. SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00 PAID
PENr'a MOTORS SEE FEE SCH.
POOR
DDREss SERVICE CHANGE 10.00 FEB 18 1983
w O ) LICENSED CONTRACTORS DECLARATION /ftx�
a u I hereby affirm that I am licensed under provisions of Chapter 9 Yl
w a w (commencing with Section 7000)of Division 3 of the Business End BLDG. ELECT. PLG. MECH.
H, o i Professions Coeandmy license is in full fore affecjn� ❑
z o= License C�l1ass GG bb Lic.Number tt'' TT ❑ ❑ ❑
Date Z- -� gam-Contracto
a Y r"BUICQINO.FERMITicf?ct;{
¢ ¢m¢ OWNER-BUILDER DECLARATION t:& E4'`s v"
Soo. t' MISC.- REFER TO ORDA_IINFORMATION_ ;
X ;LL H I hereby affirm That I am exempt from the Contractor's License VALUATION
0 4 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,after, ____T
¢ 2< improve,demolish,o!repair any structure,prior to its issuance,also ELEC.CONTR. LIC,NO. ELEC.
Ei
O LL requites the applicant for such permit to file a signed statement that TOTAL PERMIT TO
F
$m he is licensed pursuant to the provisions of the Contractor's License ,.t ,. _ ` s , . M Iw,�1 4;4
F > Law(Chapter 9(commencing with Section 7000)of Division3of the '8:' 1 FARE a.!/-7Q//1/ [f9P
¢ Business and Professions Code)or that he is exempt therefrom and QTY:. vn.t d PLUMBING PERMIT, >'-A a k FEES -F
re the basis for the alleged exemption.Any violation of5ection 7031.5 a _ t l �. v.E3 STORIES TYPE CONSTR.
d ';; _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).1:
❑ I,as owner of the properly,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 far 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
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 EG,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-11NC.40UTLETS 4.00
moots are not intended or offered for sale.If,however,the building
• or improvement is sold within one year of completion,the owner. GAS-EASYSTEM-OVER 4 IEA.) 100 BUILDING USE
builder will have the burden of proving that he did not build or int-. . . RES IND CON PS Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
O d as owner of the property,he exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractorsCod : construct the project Bea.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCELNO.
and Professions Code: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 projects with a comrnetods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B.&F.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC,DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION I WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certilicart of Workers'Compensation Insurance,or a certified
copy the ryp ec 3800,Lab.C.e
Policy N6J Companyy0/yM.�R Gla 4
0 ❑ Certifiedc py is hereby furnisher FIRE SPRINK ENERGY T24
Z Z O Cenific I with ll cfly spa lion division.
O Applicant !% MISC.- REFER TO ORD. YE] N0
y ❑ N❑
~ InPERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
CERTIFICATE OF EXEMPTION FR ry WORKERS'
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y❑ N❑
Z (This section need not be completed if the permit is for one rt^ TOTAL -
hundred dollars(SlOO)orless.) ',v.c.. -r q': M " - - t' (, 1 L yA
L) O 1 certifythat in the performance of the work for which this per- f 'I,t 'rd c n' ^t FEE.8UMMARY-
1- mit is issud,I shall nt employ any person in any manner so eto QTY' MECHANICAL PERMIT ay Mtr i �FEE.j .+z G-.. - fdi
LL ., -)? fi+ai',3n'�.>{..eA15Uu3",.: `WZ -
O become subject to the Workers'Compensation Laws of California. �r
w Dane Applicant BUILDING LJ
a ALTER OR ADD TO MECH. 4.00
} W NOTICE. TO APPLICANT: If,after making this Certificate of Ex.
I... Z 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 �3
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3400
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1C.F.M.) 5.00 SEISMIC FEE .
1 hereby affirm that (here is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work I'or which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT ITO 100,000 B.T.U.) 4.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.P.50
Lender's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all oily and Inunly PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.ar 100,000 B.T.U.) 4.00
• hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 RTU)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 agoins( h bilin s,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may any way Seen gas ns( said City in consequence cot the
gm ng of this mi MECH.CONT. LIC.NO. MECH. "' i`4" U' 1
TOTAL ,?"Y:Y� ' rS.m 7/
:, -"TOTAL
1 atom of p n(Contra or DEtC - '�P32e'.'.�>`Pr/14
OFFICE COPY