6540 (2) -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT,NUMBER
BUILDING APPLICATION & PERMIT 0
AODRFs
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
unstar.'S - PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
i216'; 6'i ( PRONP PAID
NAMERAcrons UTLETS-SWITCHES-RECEP 5.00/1.00 .
'� imp' Qn Lc.No.17 LIGHTING FIXTURES 5.00/1.00 MAY 3'1 1984
CONTRACTORS
ns
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
CON
PHONE 1J Z FJ/ PANELS 5.00 Cit 1
ifthlona
ARCHITECTSIGN$ 6.00 PLAN CHECK FEE P,C.NO,
ENGINEFR
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATED
ADDRESS SPECIAL CIRCUIT 5.00 /J•+
vP TEMP.METER OR POLE INS. 15.00
APPLI
ADDRADDRESS - MOTORS SEE FEE SCH. /Y/
,
SERVICE CHANGE 10.00
o
C
a LICENSED CONTRACTORS DECLARATION U,.- f-�
a u w I hereby affirm that I am licensed under provisionsof Chapter 9 ISSUANCE DATE
m a a- (commencing with Section 7000)of Division 3 of the Business and O ELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and of•c. �t� ❑ ❑ ❑
z °w - License Clays� ..S—Lic.Number
mDale `[7,e_.7i ' Contractor
Q y E J
¢_ ¢w Q OWNER-BUILDER DECLARATION
R
BUILDING PERMIT
°' " — INFORMATION
g¢r I hereby affirm that I am exempt from the Contractor's License MISC. REFER TO ORD
F a. o J Law fur the fallowing reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.06 VALUATION E/FT.
Ps Code:Any city or county which requires permit to construct,alter,
rt a 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. j✓ATi
°a requires the applicant for such permit to file a signed statement that TOTAL
A w m he is licensed pursuant to the provisions of the Contractor's License PEBdIT TO
H z aLaw(Chapter9(mmmencingwith Section 7000)of Division 3 of Ore )
5 Business and Professions Code)or that be is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H m the basis for the alleged exemption.Any violation of Section 7031.5 TO IES TYPE CONSTR.
a ; � by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 4.00
of not Dore than five hundred dollars(8500).1:
❑ Las owner at the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 Oc .GROUP RES.UNIT
their s1. compensation,will du ll,e work,and the structure w is not N
intended or offered for sale (Sec, 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. '4.00
Code:"file Contractors License Law does not apply to an owner of
115
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.OD SO.FT.FLOOD AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
centsare not intended oro0cmd for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owncr-
builder will have the burden Of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
prove 1,aso neeose of sale.). INDUSTRIAL WASTE INTER. 200p Es I❑ ❑N ❑ Othau
❑ I,as owner of the property,am exclusively contracting with
PS
licensed contractors to construct the project(Sec. 7044,Business - LAWN SPRINKLERS- 1 INC 5 V.B. $,DO gESESSOREPARCEL NO.
Sell Professions Code:1"he Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contacts for such projectswith a contractorts)licensed pursuant to
(lie Contractors License Law.' SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO,
❑ I aexempt under Sec. ,BAP.C.tWATER HEATER W/VT
in this EN
reason -m 4.00
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby infirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec 3800,Lab.C.). �.
Policy No. Company—x4r..G0_-IL
O „Certified copy is hereby furnished.
Z Z 9 Certifi• copy I RICO lith • fIRE SPRINK ENERGY cky inspection division. 24
O Applicant .Y✓-(�'Lre MISC.- REFER TO ORD. Y N Y [:] NE]
LUrn CERT O'ICA'FE.OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00
W _� COMI'IiNSA'1'ION INSURANCIi PLG.CONTR. LIC.NO. PLG FLOOD ZONE A.L.U.C.
9L 0 (This section need not he'completed if the permit is for one TOTAL Y 0 N Y 0 N
:D Z hundred fidlan,IS 100)or lmsJ
U O 1 certify that in the performanceof 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 o as to
became s �ect�(o{Irc Workcrs'Co en alio w f Ca Lrnia.
OF Date- - -1L f✓AnPlicam �' - 'u ALTER OR ADD TO MECH, 4,00 BUILDING
} r0 NO'I'I AIL, I'I LICAN"C It,after making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK '
provisions of the Labor Code, you most forthwith 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(OVER10000C.F.M.) 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 C.), HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender;Address HEATI NG UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify BUD l haveread this application and state that the above V ENTILATION FAN (SINGLE) 3,00
information is correct. I ogres to comply will, all city and county PLUMBING
ordinances and state laws relating to building-construction. and BOILER-DOW(3 H.P.or 100,000 B.T.U.) 4.00
hereby mauthorise,representatives of this city to enter upon the BAILER-COMP (Over 100,000 BTU(EEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
granling of thlsp• nMECH.CONT. LIC.NO. MECH.
�'' �C � r /�t� TOTAL - TOTAL
1\ S,gonlure ul Applmanl/Contractor ate _T
\ OFFICE COPY