12033 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BU I DING
APPLICATION & PERMIT 1 033
ADDRESS
1140 S. Stettin RoadBUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
H. C. Moore PHONE 253-9871
NAMECONTRACTORS' OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
Atlas Heating IC.NO.46 266 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S - APPLIANCES-RESIDENTIAL 4.00
ADDRESS'
15$ Commercial PHONE739-0516 PANELS 10.00 DATE OF APPLICATION
AnCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER -
`LIc.NO. ISIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00 PAW
ADDRESS
APPLICANT Aoness MOTORS SEE FEE SCH. -
SERVICE CHANGE 20.00 DEC 2 2 1�
Woo_ LICENSED CONTRACTORS DECLARATION
i I hereby affirm that I.ma licensed under provisions Of Chapter 9 SUANCE DATE
(commencing with Section 7000)of Division 3 of the Businessland
G, E
r N i P fessimu Code,��'nd�BJI�l cense is in lull folyy�� jjrryytt
2 o w - ])are �QI Lic.NumberA7�Q0 ❑
9 � w Dafc � ••''JJ''VV VV Contractor LL -
m f Li I Li
BUILDING PERMIT
ar a i 4 OWNER.BUILDER DECLARATION INFORMATION
w3 LL _ I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO OR yq LUATION $/FT.
F IC ma Lew for the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Anycity orcounty which requires a permit to construct,alter,
re U ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
a ea- O u requires the applicant for such permit 10 file a signed statement that TOTAL PERMIT TO
m w he is licensed pursuant to the provisions of the Contractor's License
F z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
Q _ $ the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
e- by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER IEA.) 5,00
of not more than five hundred dollars($500).):
U. I,as owner Of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code:The Contractor's License Law does not apply to an owner of
• property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 E0.FT.FLOOR AREA TOTAL ACREAGE
himself or though his own employees,provided that such improve-
mentsarenotinlendedorofferedfarsale.IL however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have'the burden of proving that he did not build or am- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
O 1,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.-7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL No,
Bnd 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.) 1.00
contracts for such projects with it contractor(s)licensed pursuant to
the Comractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
O' I um exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner - Data WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereptr6yu^ 3gjIQ,Lab,C.). Al l i �u b
Policy No.Li W $repany ed P�
O 6 Certified copy is hereby famished. FIRE SPRINK ENERGY T 24
Z Z Q Cer fticg� iH 1W'9ba city inspection division. MISC- REFER TO ORD.
F O Applicant 6 Y ❑ NE] YE] N❑
CC T C17RTIFICATE OF EXEMPTION FROM WORKERSPERMIT ISSUANCE • 10.00 - FLOOD ZONE A.L.0 c.
LU J COMPENSATION INSURANCE PLC.CONTE. LIC.NO. PLG. Y E] N E] V E] N❑
Z ('Phis section need not be completed if the permit is for one TOTAL
hundred dollars(S 100)ar less.)
V O 1 certify that in the performance of Ilia work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued,1 shall not employ any person in any manner s0 as to
O W DO la the Workers'Compensation Laws of California. BUILDING
Q_ Date Appllcanl ALTER OR ADD TO MECH. 5.00
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex
N Z emption,you should become subject to the Workers'Compensation 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 ITO 10=131F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000.RM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
tum performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT ITO 100,000 B.T.U.) 8.00 8.06
Tender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 1 ELECTRIC
. I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating m building construction, and BOILER•COMP(3 H.P.Of 100,000 B.T.U.) 6.00
hereby authorize representatives of this city l0 enter upon lira BOILER-COMP (Oval 100,000 BTU)SEE FEE SCH: MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichCONST.TAX
may in any way accrue against said City in Consequence of the PERMIT ISSUANCE 10.00 0.00
gruntingafthispermit. - MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature of Applican t/Contractor Date Atlas Heating 4666 $18.00
OFFICE COPY