8643 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
A°DRESB 8643
0603" ,�e0 2a 04/9/& BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'$ ''k rr PLA<� AId LIDATION
NAME 141/
QTY. ELECTRIC PERMIT `FEE
coNTRACTORS 61�E-
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 MAY 10 1985
AMM' 4eFeO /NG LIC.NO. .3/,33�L LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES 4.00
ADT �'YxkE City of Cupertino
OREss
El 7AP'40' Z/E PHONE 71JS-VO PANELS 10.00 DATE OF APPLICATION
on
ARCHITECTPANELS (OVER 200 AMP) 20.00 ' PLAN CHECK FEE P.C.N0.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
AVIDAIO
R. ENG. ` PERMIT ALyN
ADDRESS
- SPECIAL CIRCUIT 5.00 /}CI DA
ZIP rrEMP.METER ORP LE INS. 20.00
APPLICANT$
ADDRMOTORS SEE FEE SCH.
ESS {/
9 E, lr4-Y" ,f e,6, S�liA26 SERVICE CHA GE 20.00
w o o LICENSED CON'rRACORS DECLARATION TEMP.PO E' 30.00 a �.
a v w I he,chy affirm that I am licensed under provisions of Chapter 9 1 SUANCE DATE
Li(c0 mmenc ing with Sec lion 7000)of 1)ivision 3 of the Business and CT.a n BLDG. PLG.
, MECH
r N z Professions Code,a 1 ty license is in full force and effect. ❑ El E]o z v_i o renu Class(_ 1-7„ Lia Nmnbcr�J.j31��a
IV
Date Contractor
3 /biz 'aT'G9-ldG�-
¢ m s a OWNER.BUILDER DECLARATION BUILDING PERMIT/
a a o / INFORMATION
is ; u m I hereby affirm that I am exempt from the ContractorREFER TO ORD
's License. MISC.-
r wO j Law for the following ruuson.(See 7031.5,Businessand Professions PERMIT ISSUANCE 10.00e VALUATION $/FT.
CodAny city or county which requiresa permit to construct.alter,
e, ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
E O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
rz >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom andDTV. PLUMBING PERMIT FEE
¢ r$ the basis for the alleged exemption.Any violation of Sect ion 7031.5 STORI TYPE CONSTR,
a � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAM& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.0 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. . 0
Code:'I'hc Contractor's License Law dues not apply to an owner of
property who builds Or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If.however,the building GAS-EA.SYSTEM-l1NC.4OUT S_ 6.00
or improvement is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 ( .) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purposeofeale.). INDUSTRIAL WASTE INT 30.00 E IND CON PB Omer
❑ 1,as owner of the property,um exclusively contracting with ❑ ❑
licensed mntramors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 C 5 V.B. 6.00 ASSESSORS Pgge EL NO.
and Professions Code:The Contractor's License Law dues nut apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS VER 5 IEA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITAR -STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&KC.for this WATER HEAT W/VENT 6.00
rens n
Owner Date WATER SYS M 5.00 ACC.DATE ACC.FILE NO.
WORKERS'CONPI NSATION DECLARATION WATERT EATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self-insure,
or a certificate of Workers'Compensation Insurance,or it certified ZONING ENG.SITE NO.
copy thereof(Sec,3800,LaDCL
Policy Nn. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY L20
Z Z (Y Certified cop Is file wit�city inspe}tion division.
O Applicant ��//'/���� MISC- REFER TO ORD, YC] N� v ❑ N�
CCN CERTIFICA'rl!OIi XI- IPTIO °MIROMOM WORKERS" PERMIT ISSUANCE 10.00
h FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. UC.NO. PLG.
C 0 frhis section need not be completed if the permit is for one TOTAL Y N v N
::I Z hundred dollars IS 100)or less.)
0 O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any nmnner so as to
0 w become subject to the Workers'Compensation Laws of California.
DO Date-Applicant 111 LDI NG
} m NOTICE 'r0 APPLICANT': If,after making this Ccrtificat of 1!x- ALTER OR ADD TO MECH.
F ?
coalition,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(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0=C.EM.) 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.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4:00
• ordinances n correct. agree to comply with all city and county r PLUMBING
IndoRnnccs and stat, laws relating m building l City construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property forinsp of this
purposes.
(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 10.00 CONST.TAX
may in any,way accrue against said City in consequence of the
granlin of this permit./ ret or Uate MECH.CONT. LIC.NO. MECH
TOTAL
Si roe of App.. MZ 1MJIM
,/ .
TOTAL ✓T(P
INSPECTOR COPY
I