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9204 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENT]FICATI ON PERMIT NUMBER r � BUILDING 3{ APPLICATION & PERMIT ADORE 10 e /X / 1 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 920.4 4.�• OWNER'S r PLAN CHECK VALIDATION , T NAME c-��C/ �y. ELECTRIC PERMIT FEE My Pd1HONVE PAID �( ry RAc*oRs OUTLETS 10.00/1.00 / - -- "G N. LIGHTING FIXTURES 10.00/1.00 JUL 12 1,985 CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 ADDRESS S•3%Zt PHONE PANELS 10,00 TIhTION oR "TECI PANELS (OVER 200 AMP) 20.00 P.c.No. ENGINEER LIC,NO, SIGNS TRANS. 3.00 ADDRESS eua SPECIAL CIRCUIT 5,00 PERMIT VALIDATIONNo ZIP EMP. METER OR POLE INS. 20.00 APPLICANT S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 F... i W LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00' �/p G o I hereby affirm that I am licensed under povi,ion,of Chapter 9 ISSUANCE DATE a fconuneneing with Section 7000)of Division 3 of the Business and �i a c BLDG. ELECT. PLG. MECH. F w Pofrssions Code,and m license is in full force nd effccl ❑ © ❑ ❑ z o,i, - Liceve Clas. Lia Number O z H o Date ErfContract., c m BUILDING PERMIT rc a OWNER-BUILDER DECLARATION z o W U r INFORMATION R g u _ I hereby affirm that 1 an exempt from The Con tmclor5 License MISC.- REFER TO ORD LL o< Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT. - N g PERMIT ISSUANCE t0,00 VALUATION Any city or county which Struiture permit oconstrue,.also Q ¢ 1 0 improve,demolish,or repair any slntcture,prior o its issuance,also ELEC.CONTR. LIC.NO. ELEC. D a, requires the applicant for such permit to file a signed statement that TOTAL 6 Wm LL he Is licensed pursuant to life provisions of the Contractor's License PERMIT TO '- i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe H z a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE E'46-G7, fE o H m the basis for❑@ alleged exemption.Any violation of Section 7031.5 malty STORIES TYPE CONSTR. A � .- by any applicant fora permit dollars lheapplicam oacivil penalty ALTER-DRAIN -WATER IEA.) 5.00 of not more than five hundred dollars(55001.): ❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCD.GROUP RES.UNITS their sole compensation,will do The work,and the structure is not intended or offered for sale (Sec 7044, Business and 1'rol'essions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 Code:T'he Contractor's License Law does tot apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP5.00 .So.FT.FLOOR AREA TOTALACREAGE • himself or through his own employees,provided that such improve- ments arc not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-1 INCA OUTLETS 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 of proving that he did not build or int- BUILDING USE Prove for pu,pou of sale.). INDUSTRIAL WASTE INTER3000 RES 'IND CON PB Code, O n I,as ower of the property,gn . . i cschoase,contracting with ❑ ❑ ❑ ,❑ ❑ licensed comraclors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO, Slid Professions Code:'I'he 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 a contractods)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ I;un exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 mason Own,; Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO, WORKERS'COAIPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent to self-insure. or a certificate of Workers'Compensation Insurance,or it certified ZONING ENG.SITE NO. copy tire re.f(Sec.3800,Lab,C) ' Policy No- 0 11 Certified copy is hereby fun 11 (1. FIRE SPRINK ENERGY T-24 Z Z h7Oerty/ 'nfaction division. O _ h MISC. REFER TO ORO. Y ❑ N❑ V ❑ N❑ M -� CERTIFICATEOF EXEMP1'ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.UA. LU > COMI FNSATION INSURANCE PLG.CONTR. LIC.No. PLG. CL 0 (1 In, section need-not he completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑ ::IZ hundred dollars(S 100)or less.) U O 1 certify that in Bie performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY LL I- mil is issued.I shall not employ'any person in any manner so as to become subject to the Workers'Compensation Laws of California. 0 a Dare Applicunl ALTER OR ADD TO MECH. ,5.00 BUILDING } N NO]ICE '10 APPLICANT: If,after making this CI,niticac of Ex- _ F Z emption,you should become subject to the Workers'Compcnwticn 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 10=C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.F.M.) 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(See. MICROFILM 3097,C'iv.C'.)� H EATING UN IT(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 t I cerlily that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 O m orination is correct I agree to comply with all city and counlY PLUMBING ordinances and slate laws relating 1n building 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 above-mentioned property for inspection purposes. BOILER-COMP(Over 100,0008TUl SEE FEE SCH. MECHANICAL (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 grantii g oI this p nnit. CH.CONT. LIC.NO. MECH. oTAL TOTAL Si o' pPlic o r or • 41 INSPECTOR COPY ' r r I