18657 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
ADDRESS LDING APPLICATION & PERMIT115 1.51 ��+ ��
r) BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
NER'S PLAN CHECK VALIDATION
NAME
OTY. ELECTRIC PERMIT FEE
,1 Ir. LI W S PHONE
CONTRACTORS
6N E .}r ,J IfUTLETS-SWITCHES-RECEP 10.00/1 � P AQ
�i 11OrTd nr UC.NO. 1 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES+RESIDENTIAL 4.00 JUN 30 1992
ADDRESS J ✓�
' -6 65ier h(m PHONE 11 I PANELS 10.00 ATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAbI E r
OR
ENGINEER -
UC.NO. SIGNS TRANS. 3.00
ADDRESS D,ENIPE�S pyLT VA A� �_110,tI rI
ZIP EMP.METER OR POLE INS. 20.00 TS�f`+l,(
APPLI s
AODROR ESS MOTORS SEE FEE SCH.
Ess
SER VI .00
E 2
w a0 2. LIC17NSED CONTRACTORS DECLARATION _
a u w 1 hereby affirm that 1 ani licensed under provisions of Chapter 9 • ISSUANCE DATE
H (conmtencln with Section 7000)of Division 3 of the Business and -
¢ S BLDG. ELECT. PLG. MECH.
r m i Professions Co Ji,a y license is in full for a sLi f•ct. ❑ ❑
o0 M o Licensyy b�ts' Lic.Numbe b
r N f j Date�[�41I�4-3_Contractor S(2-M l DATE Cl
¢ s: Alin ��+ BUILDING PERMIT
¢ 2. a OWNER-BUILDER DECLARATION
a eu U INFORMATION
E:
;n y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
e_ W_
Law for the following reason. 7031.5,Businessand Professions PERMIT ISSUANCE 1000 VALUATION S/FT.
fw Code:Any city or county whiehrequiresa permit toconstrum alter,
Q a,¢D Improve,demolish,Or repair any Structure,prior to Its Issuance,also ELEC.CONTR. LIG.N0. EL
n wO Ci u requires the applicant for such permit to file a signed statement that TOTA `I PERMIT TO
w he is licensed pursuant to the provisions of the Contranor's License
FZ >
Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the
¢ Business and Professions Cock)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
i o
¢ how the basis for the alleged exemption.Any violation t to a cion malty STORIES TYPE CONSTR.
by rd[not tha for a pearl subjects the 0).): urn toacivilpenalty ALTER-DRAIN -WATER IEA.) ,5.00
of not wore than live hundred Dollars(8500)J: -
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves Thereon,and who docs such work F IXTURES-PER TRAP 5.00 SM FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve
morns are not intended or offered for sale.If,however,the building
iGAS•EA.SVSTEM-11NC.40UTLETS 6:00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden o'proving that he did not build or im- BUILDING USE
prove for purpose ofsale.), ' INDUSTRIAL WASTE INTER. 3000 RES IND CON PB Orbe
m .
❑ I,as owner of the property,aexclusively contracting with 1:1 1] ❑ ❑ E]licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. B.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs 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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE No.
WORKIiRS'COMPENSATION DECLARA'I'ION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of......Lot mself-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof IS,- 38`00,Lab.C.1( ,spm
1'ol icy Na&If-.Z y'{�i°nye V7 X_IQ�
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z Cort ¢d_}/Opy,is Iledy wLti 'IIc y
O Applicant inspa•'ti ivisinn.
MISC.• REFER TO ORD. Y❑ IN❑ v ❑ rv❑
a N CF.RTI FICATE Oh EX EMPI'ION 17RCIM WOR K Ii RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTE. LIC.No. PLG.
(L a (This section need not.he completed if the permit is for me TOTAL Y❑ N❑ Y [D IN C]
Z
hundred dollars($100)or hese.)
U 0 1 certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
O L) become subject to the Workers'Compensation Laws of California.
y Dale ApplicantBUILDING
>_ DO NOTICE TO APPLICANT: If,after making this Certificate of fix- ALTER OR ADD TO MECH. 5.00
Z emptlon,you should become subject to Iha Workers'Cin liensution APPLIANCE 5.00 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 10000C.F.M.) 4.00 C.CJ
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.I 6.00 SEISMIC FEE
I hereby affirm that There is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5,00
the performance of the work for which this permit is issued(Sec. MICROFILM
- 3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 6.0
Lender's Name HEATING UNIT(0 VER 100,000 B.T.U.)8.50 ELECTRIC
IF
Lender's Address
certify That I have read Odsap ion annd atate Dim thehove VENTILATION FAN (SINGLE) 4,00
information is correct. I agree to com comply ,all city and county PLUMBING
ordinances and stale laws relating ID building Construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purr mcs.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10. CONST.TAX
may in any way accrue against said City it consequenec of the
coli Of this permit. MECH.CONT. LIC.NO. MECH.
AZ-21-42,
-R9 4) TOTAL TOTAL
Signature of Applicant/ tactor - Dates ( 1_ i
OFFICE COPY