C 6110 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICAT16N ' PERMIT NUMBER
BUILDING APPLICATION & PERMIT '
aooR EssBUILDING -ELECTRICAL—PLUMBIN '6110
g
61qO9
—MECHANICAL
NAME
NAME �—�1 •' PLAN CHECK VALIDATION
PRON
_42' 7yp CITY-1 ELECTRIC PERMIT FEE
x•1`}5 , GL AG7
( cOrvrRACTDRs
NA OUTLETS-SWITCHES-RECEP 5.00/1.00 PA O ,
�v ,yS:rRi ��-'
`4t55ic.No.V1 ,91 LIGHTING FIXTURES 5.00/1.00
P -
ONTRSSTORS APPLIANCES-RESIDENTIAL 4.00 JUL 12 1985•
A.
r (/ PHONE O PANELS 5.00 ATE OF APPLICATION
RCNHECT
OR m Z/ 9��73
Dl� SIGNS 6.00 - G no PX.NO.
ENGINEER .. ,
LIC.No, SIGNS TRANS. 3.00
ARCH.OR ENG. - P RMIT VALIDATION
ADDRESS SPECIAL CIRCUIT. '5.00
Z,P• EMP.METER OR POLE INS. 15.00 -
APPLICANT'E ,
MOTORS 'SEE FEE SCH. '.
4; SERVICE CHANGE 10.00
0
-0VVV
Foo LICENSED CONTRACTORS DECLARATION -
a u •I hereby affirm(hat [ant licensed under provisions of Cha ter9 .�
• F 2 w p s ISSUANCE DATE
w G H (commencing with Section 7000)of Division 3 of the Business and BL ELECT. PLG. MECH.
F m A ProfessCOJ license is in full fo • �E19/1
� - ❑ ❑ ❑
o 0 w o Licenu ClCla Lic.Number O �^/�-& ��
Dale Contractor
¢_ IS wa - OWNER-BUILDER DECLARATION t � ` BUILDING PERMIT
D MI C.—, - REFER TO ORD INFORMATION
X ;n w I hereby affirm that I am exempt from the Contractor's License
u o e Law for the following reason.(Sec.7031.5,Business and ProfessionsPERMITISSUANCE VALUATION $/FT-
w > Code:Any city or county which requires permit to construct, 6.00
alter,
a a, It 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. CIC.NO. - ELEC.
G B, requires the applicant for such permit to file a signed statement that _ TOTAL
U.n w m he is licensed.pursuant to the provisions of the Contractor's LicePERMIT TO
nse -
Fii
Law(Chapter 9(commencing with Section 7000)of Division 3 of the a
4i o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE /�,•,[-, /�-�
F m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3— by any applicant for a permit subjects the applicant tourist penally ALTER-DRAIN (EA.)of not more than five hundred dollars($500).): / .. - -
❑ I,as owner of the property,or my employees with rewages as
not BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,e will property,
the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 4.00
Code:The Contractor's License Law does not apply to an owner of '
propertywhothrough
builds hhiso nemplSthes, n,and provided
that oessuch
improve.
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.40UTLETS'4,00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM=OV ER'4 (EA.) . 1.00' BUILDING USE
prove for purpose of sale.). - INDUSTRIAL WASTE IN TER. 20.00 E IND CON'- PB Omer
Hat❑ I,as oner of the property,am exclusively contracting with 7 O
licensed cont [o 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 an owner of property who builds or improves thereon;and who LAWN SPRINKLERS-OVER 5(EA.) 1.(0
contracts for me projects with a contractors)licensed pursuant to -
theContractor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec,.,B.&P.C.for this
reasonWATER HEATER W/VENT - 4.00 ''
Ow�+nerj� ` Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
'Tt <"1dISRICE SYSW SAT o DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm [hat I have a certificate of oonsmrt to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
cD�Y Ihereol ec 3SOQ Lab.C.) M,Q ,
Policy No. Company �/Mr f
z z
❑ Cetlili dcDpy is hemhy furnished. FIRE SPRINK ENERGY T-34
y� Certified copy Is Bled wish the Illy inspection division.
p A{ip�icanf MISC.- REFER TO ORD. v ' N� v � No .
L4 CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (This section need not be completed if the permit is for one TOTAL Y O N� xY N�
::) Z hundred dollars($100)or less.) -
U O. 1 certify that in the performance of(he work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall no[employ any person in any manner So as to,
O
U become subject In the Workers'Compensation Laws of California. t/
IS. Date Applicant I ALTER OR ADD TO.MECH. 4.00 BUILDING zr 60
>_ DONOTICE TO APPLICANT: If,after making this Certificate of Fx-
�F 2 cnlption,you should become subject to the Workers'Compensation APPLIANCE 400 PLAN CHECK
Provisions of,the Labor Code, you must fotl .
hwith comply with
U - such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.RM.) 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(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Leader's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Icertify that bhave readthis application and State that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all city and county BOILER•COMP(3 H.P.Of 100,000 B.T.U.) 4.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby authorize representatives of This city to enter upon the
bove-mentioned property BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
aproperty for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. -
Cupertino against Babililies,judgments, costs and expenses which CONST.TAX `
may way acer gains Said City in Consequence of the PERMIT ISSUANCE 3.00 . I -
gr mg h per MECH.CONT. LIC.NO. MECH.
TOTAL' TOTAL
Signature of Applicant/Conlmetor Date '
OFFICE COPY