3785 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT[FI CATION PERMIT NUMBER
BUnLGrNc APPLICATION & PERMIT ^ 17
ADDRESS �� �- " __BW GT 3 I
aj,OCr -1 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
85
NWNER'5 "iI'r 1 PLAN CHECK VALIDATION
OTV. ELECTRIC PERMIT FEE
V /Pj T) r S)v PHONE #34-011
CONTRACTOR'SUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
U< <J Ia NO. Q LIGHTING FIXTURES 5.00/1.00
CONTRACTOR', 11 aP'1✓%r.-1 APPLIANCES-RESIDENTIAL 4.00
S K JA/ VTV" PHONE o/ (J(p�Q PANELS 5.00 DATE OF APPLICATION
ARCHITECT6.00 PLAN CHECK FEE I P.C.NO.
OR SIGNS
ENGINEER
L.C.No. SIGNS TRANS. 3.00 �RAy ygI,
ARCH,SS ERG. SPECIAL CIRCUIT 5,00 Pl Al✓ AT
TIP EMP.METER OR POLE INS. 15.00 i
ADDRESSTS MOTORS SEE FEE SCH. (JUN $@ 1983
SERVICE CHANGE 10.00 1
X o LICENSED CON TRACIORS DECLARA't10N City of Cupertino
G u I hereby affirm that I am licensed under provisions of Chapter D ISSUANCE DAT
c ftonmcncing with Section 7000)of Division 3 of the Business uoJ
N"
o m _ .
MECH.
'rolessios Codh License
licent srisNl fullf11oi Dal �CoNmnor-
XMILM
a w oe
< y BU
OWNER-BUILDIR DECLARATION IDINMG RMIT
FOION
oA MISC.- REFER TO ORD
-� 3 u y I hereby affirm that I am ex empl from the Contractor's License VALUATION $/FT.
w• u Oj Law for the following reaso n.(Sec.703 t.5.Brrsinessand Professions PERMIT ISSUANCE 6.00
to Code:Any city or county which requires a permit to construct,alter,
2 ¢ Q 2 imJJID
prove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
E O u requires the applicant for such permit to file a signed statement that TOTAL /l PERMIT TO
a w w he is licensed pursuant to the prosi .....of the Contractors License �+
Fii law(Chapter 9(commencingwith Section 7000)of Division 3 of the S%TOA `7 .3Q.q-//U/
Q business and Pm essions Code)or Ihnt he is exempt therefrom unit DTV. PLUMBING PERMIT FEE
M _$ the basis I'or the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR,
u , by any applicant fora permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not mora than five hundred dollars($5000.).
❑ I,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:'rhe Conlmaor's License Law does not apply to an owner of
property who builds or Improves Iltereon,and who docs such work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself through his own employers,Provided Out such improve-
merits arere m
not intended or offend e sale IL however,the building GAS-EA.SYSTEM-1 INCA OUTLETS 4.00
or improvement is sold within one year of completion,the owner-
MlGAS-EASYSTEM-OVER 4 (EA.) 100 BUILOINGIISE
builder will have the burden of proving that he did nbuild . . .
or int- RES I C le PB Omer
prove for purpose lrf`sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,its owner of the property,ant exclusively contracting with
Iiccnscd contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSO 5 PPRCELNO.
Intl Professions Code:Thr 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 contractor(s)licensed pursuant to
the Contractor's Licenze Law. SEWER-SANITARY-STORM EA. 200ft/8.00 TRACT NO. PARCEL No.
❑ Iwncmmpl under Src. ,B.&PAC.far thin WATER HEATER W/VENT 4.00
on
Date Ow'ns'r WATER SYSTEM 4.00 ACC.GATE ACC.FILE N0,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a cc"
ifcide ofcoraeot to all-inner, TONING ENG.SITE NO.
or a certificate of Worker,'Compensation Insurance,or a certified
\� copy thereof(Sec.3800,Lab.C.).
Policy No. m
Copany-/,Aj& /tC� til
z E) Ccrtificd copy is h erchy furnished. FIRE SPRINK ENERGY T-24
Cl C,rtill,ittlopy Is - wit c ci inspc ion diviwnl' MISC.- REFER TO ORD. YQ' N� y � N�
O APPlicam _ -
D: N Cl, I'ICATIi OF EXEM1i71ON FROM WORK ERS' PERMIT ISSUANCE 6.00 f FLOOD ZONE A.L. c.
LU � COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. V N v ❑ A
d 0 ('this action need not he completed if the permit is far one TOTAL
Z) Z handled dollar,(SI00)or IF,,)
U O 1 comfy that in the performance of tile work furhi
wchbi
Poster- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I zf all not employ any person in any manner so as to
OL) become subject to the Wcukeni Compcnzmmut Law,of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 4.00
- y NOTICE TO APPLICANT: It,after making this Certificate of Es-
F Z_ eruption,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you mus[ forthwith comply with FEE
U such provisions or this permit shall be decnreJ revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency I'or EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this pennit is issued(Sec. MICROFILM
3077,Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Z50 ELECTRIC /.( Ou
Lender's Address
Icertify that l havercad Ihis.,plication and,tate that theabove VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00 PLUMBING � C
ordinances and stale laws relating to building construction. and
hereby zutmrHc representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
I above-mentioned property for inspection purposes.
II` (we) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgnnents, costs and expenses which CONST.TAX
ma any way accrue a ninst said City in ronseq ten of the PERMIT ISSUANCE 3.00
nl gnf thi hit. MECH.CONT. LIC.NO, MECH.
6 , 3 oTAL TOTAL
'gmatare of Applici n/ a :rotor
r
OFFICE COPY