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5436 (2)oQC. foC. Q U V Nzw ¢ d w Oz�w FF Q y E J Q Q w U X; FLLoj fw>s Qn00 mw o W r i c iQo Q r $ s 3 Is I 0 1/,1 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ALY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING —ELECTRICAL— PLUMBING —MECHANICAL PERMIT NUMBER ^ b BUILDING ADORES OWN LC/_ r1 L /-r�/S'O r,/ NA HGNE .. a .'„ x, .. 0/,k., OTV: -` ''-ELECTRIC :IPERMIT._' PLAN CHECK VALIDATION PAID 16 1984 APR .�{p - OAIY AQATION CONTRACTORS NAME'A iZ326Q NyCT,CKD, OUTLETS -SWITCHES - RECEP 5.00/1.00 LIGHTING FIXTURES 5.00/1.00 CADORES ) ONTRACTORS LAPPLIANCES-RESIDENTIAL 3b j V(� ViPHONE�LS -I b2 - 4,00 PANELS 5.00 ARCHITECT OR S,, ar'el ENGINEER JJ �1 ' uc. uo. - SIGNS 6.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ARCH, OR ENG. ADDRESS SPECIALCIRCUIT 5.00 PERMIT VALIDATION ITEMP. METER OR POLE INS. 15.00 ' ZIP A ADDDRESSDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 LICENSED CONTRACTORS DECLARATION ' 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cade, andAry license is in full for no efte License Class— Number' d' ISS CE TE BLDG. ELECT. LG MECH. ❑ ❑ ❑ _ Con Dale Contractor OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Code:Law Any citylowing ounly on.chreg03sa permit tocnd Professions Code: Any city or county which requirese permit to construct,, also improve, demolish, L of repair any 9watofi prior n its issuance, also lu ole a Cont statement i that requires the applicant fir Such provisions of the )ofDreision License he is licensed pursuant to the with Law (Chapterand Pr (commencing Or Section is exempt Business and Professions Code) or [hal he is exempt therefrom and pt the of om and the basis for [be alleged exemption. Any violation of Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): '4 �BUILyOING�P INFORMN RMIT -llO MISC.— REFER TO ORD PERMIT ISSUANCE 6.00 VALUATION S/FT. ELEC. LONTR, I LIC. NO. TOTAL TOTAL QTY. kl"y 1°"!P,LUMBING P,,ERMIT AN TR. �, - `' ` • - RAN �N +, +. 777* . 4 b A I RMIT TO ' STORIES T PE CONSTR. ALTER -DRAIN & VENT -WATER (EA.) 4.00 ❑ 1, as owner of the property, or my employees with wagesas their sole compensation, will do the work, and the structure is not BACK FLOW PROTECT. DEVICE 2.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 4,00 intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of FIXTURES - PER TRAP 4,00 GAS - EA. SYSTEM -1INC. 4 OUTLETS 4,00 property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- ments are not intended or oo'cred for sale If, however, the building SQ FT. FLOOR AREA TOTAL ACREAGE 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- prove for purpose ofsale.). I, as owner of the property, an exclusively contracting with GAS - EA. SYSTEM -OVER 4 (EA.) 1.00 BUILDING USE E MD CON PB Omer El 1:1 11 El❑ INDUSTRIALWASTE INTER. 20.00 LAWN SPRINKLERS- 1 INC 5 V.B. 5A0 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 licensed contractors to construct it,, project (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who ASSESSORS PARCEL NO. contracts for such projects with a contractor(s) licensed pursuant to the Contractor, License Law. - ❑ lam exempt under Sec. ,B.&P.C. for tllis reason SEWER -SANITARY -STORM EA. 200ft/6.00 RACT NO. PARCEL NO. WATER HEATER W/VENT 4.00 Owner Date WATER SYSTEM 4.00 ACC. GATE ACC. FILE NO. WATER TREATING EQUIP. 4.00 WORKERS'COMITNSATION DECLARATION 1 hereby affirm that I have a ceNifnTte of co _ or a curtificam of rkers' Compensation Ins ZONING ENG. SITE NO. copy iher 1. Pop n n n I.W= iir 5 .�. verified copy is hereby furnished. ertifi i N d oh the city inspection division. App many MISC.- REFER TO ORD. FIRE SPRINK v� N� ENERGY RP4 V[] N[] CERTIFICATE OF I iXEMPTIJN FROM WORKERS' COM%iNSAI'ION INSURANCE: (This section need no[ he Completed if the permit is for one fit) PERMIT ISSUANCE 6.00 cry FLOOD ZONE Y [:] N A.LU.C. Y 0 N 0 PLG. CONTR. LIC. NO. PLG. TOTAL hundred dollars l$ 100) or loss) 1 certify that in the performance of the work for which this per mit Is Issued, 1 shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of Cxlifoima. Date Applicunt - pp +q e� rv,, UTVT f(n ^rry NVIIIIECHANICAL�PERMIT '1' wf 1 F E .K n e { y,.-, I - I9; FEE SUMMARY BUILDING ALTER OR ADD TO MECH. 4 G01 NOTICE TO APPLICANT: If, after making this Certificate of Ex- APPLIANCE 4.00 AIR HANDLING UNIT (TO lO=C.F.M,) 3.00 PLAN CHECK FEE emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you most forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(OVER 10,000QRM.) 5.00 SEISMIC FEE CONS'T'RUCTION LENDING AGENCY - I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ.CJ. - EXHAUST HOOD (WITH DUCT) 2.00 MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 4.00 Lender's Name Lender's Address - - HEATING UNIT (OVER 100,000 B.T.U.P.50 ELECTRIC I certify that 1 have read this application andstale that the above information is correct. I agree to comply with all City and rountg ordinances and state haws, relating to building construction, and VENTILATION FAN (SINGLE) 3.00 PLUMBING BOILER -COMP (3 H.P. or 100,000 B.T.U.) 4.00 hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. BOILER -COMP IOver t00,0008TU15EE FEE SCH. MECHANICAL (Wc) agree to save, indemnify and keep h:,.IcSs the City of MISC. - REFER TO ORD. Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said'City in consequence of the PERMIT ISSUANCE 3.00 CONST. TAX - grant =,R. �— f��(f�//'J I —•psi man LT MECH. CONT. LIC. NO. MECH. TOTAL r TO-,TAL' 14 0 Signature of Apphcanl/Conlmelor Date OFFICE COPY