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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
6157
BUILDING
ADDRESS
i D 3 EL C
OWNER'S
PLAN ECK VALIDATION '
NAME -F A/� �, ((\ /J �j /'
V. \ 5- l PHONE I, S&
OTY. ELECTRIC PERMIT FEE
DATE OF APPLICATION
NAME Ac70R's
' CD S X110ES LIC.NO.
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACTORS A
AODRES �/
L/ NONE ,V6
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
ARcNITECT
OR
ENGINEER
LIC. NO.
SIGNS - 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENO. -
ADDRESS
SPECIALCIRCUIT 5.00
PE9MSZ )151iDATION
ia9E6r
TEMP. METER OR POLE INS, 15.00
ZIP
1 9 1985
MAR
''rin" 1 1.7ve1
ADDRESS
ADDRESS
MOTORS SEE FEE SCH.
SERV ICE CHANGE 10.00
k711 7t SWf-A CWA
City of Cupertino
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
Professions Cade,' d my license is in full for an e f
License Cl S Lie
BLDG.
ELECT.
El
PLG. MECH.
El,
Datc_i vMl(y1 l{T�1y�-- Conlrn<tbr
V''
OWNERI am exempt from TION
1 hereby affirm that 1 am exempt from Om Contractor's License
Law for thefollowingor count son.ch c. reg03ta perminess andt town Professions
Any city or county which structure,
imprCodeove, tru tura permit taco issuance, also
inquires demolish, or repair any structure,priorto its issuance, also
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
VALUATION
S/FT.
-PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO.
ELEC.
requires Lfle applicant for such permit TO rile o signed statement that
he is licensed pursuant to the provisions of the Contractor's License
TOTAL
PERMIT T 91
OTV. PLUMBING PERMIT FEE
Low (Chapter 9 (commencing with Section is ese of Division 3 of the
Business andfor Professions Code) or that he is pt therefrom and
�+N
STOR S
TVP CO TR.
the basis for the alleged exemption. Any violation of Section 703 LS
tion
by any applicant fora Permit Subjects the applicant to a civil penalty
otter more than five hundred dollars ($500).):
-
ALTER -DRAIN& VENT -WATER (EA.) 4.00
❑ I, as owner of the property, or my employees with wages as
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, T'he Contractor's License Law docs not apply to an owner of
FIXTURES - PER TRAP 4.00
50. FT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsarc not intended oroffered for sale. If. however, the building
GAS - EA. SYSTEM -11NC, 4 OUTLETS 4.00
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 of sale.).
❑ 1, as owner Of the properly, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.) 1.00
BUILDING USE
RZgA IND CON PB Direr
❑ E] E] ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS -I INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO,
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: T'he Contruclor's License Law does not apply
to an Owner of property who builds or improves thereon, and who
contracts for such projects with a contraetranto licensed pursuant t0
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ l am exempt under Sec, ,B.&P.C. for this
mason
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO,
WORKERS'COMPFNSATION DECLARATION
WATER TREATING EQUIP. 4.00
I hereby affirm that I have n certificate of consent to sclEinsure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE N0.
copy tnerenr�se=. 3gpg,l
Policy No I 11 )
�!%I l�
M - REFER TO ORD.
FIRE SPRINK
Y ❑ N❑
ENERGY T-24
V ❑ N❑
Crnt ted pY. ereby❑I ishcd.
❑ CeISC. ti s I inspection division.
APPIiC�n _ _
_- CERT ICATE 01: EXEMPTION PROM WORKERS
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U,C.
PLG-CONTR. LIC. NO.
PLG.
TOTAL
COMPENSA'T'ION INSURANCE
(This se lion need not be completed if the Permit is for One
Y ❑ N❑
Y ❑ N❑
QTYMECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars ($100) or Ie.4)
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 s0 as to
become subject to the Workers' Compensation Laws of California.
Dan ApplicantALTER
BUILDING
i(%I
M. U(/
OR ADD TO MECH. - 4.00
NOTICE TO APPLICANT: If, after making this Certificate of IN-
enmtion, you should become subject to The Worken' Compensation
APPLIANCE 4.00
PLAN CHECK
provisions of the Labor Code, you most forthwith comply with
samh Provisions or this permit shall be deemed revoked
AIR HANDLING UNIT (TO 10MC.F.M.) 3.00
FEE
AIRHANDLING UNIT(OVER 10MIC.F.M.) 5.00
SEISMIC FEE
67)
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
1 hereby affirm Heat there is a construction lending agency 1'or
the performance of the work for which this permit is issued (Sec.
3097, Cie+C.).
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7,50.
ELECTRIC
-
Lender's Nano
Leader's Address
FAN(SINGLE) 3.00
PLUMBING
I cattily Rod l have read this application and state that the aboveVENTILATION
information is correct. I agree to comply with all city and county
ordinances and state laws relating to buildingConstr.C'mm, and
BOILER•COMP(3H.P.orlOO,000B.T.U.1 4.00'
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
-
hereby authorize representatives Of this city to caner upon The
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino ago' l liabilifi , judgments, costs and expenses which
may in any accrue against said City in comae uence of the
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO,
MECH.,
TOTAL
TOTAL
I
gra ermit n-
JCA �
Sig arepplicant/Contractor to
OFFICE COPY
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