86390¢i
"00
LM
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
BUI LOI NG PRO E VNTI FIC 3N
-
APPLICATION & PEnIVIIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
8639
..II.ING. . I
t�.I
40"70 D. A!,ji
o E.3
NAME.3
A, '"'iELECTRIC PERMIT�f--,,-SzWV,i FEE'.',
PLAN CHECK VALIDATION
IINAMERACTORsn
ft c. NO 2- 2. If 7 1/
L ETS -SWITCHES - RECEP 10.0011.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS
APPL IANCES - RESIDENTIAL 4.00
PANELS 10.00
PHONE -6
AEP
DATE OF APPLICATION
-CHECK
ENGINEER 3 q
LIC,
PANELS (OVER 200 AMP) 20.00
--FLAN FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH, OR
ENG.
V zip
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. -20:188
APPLICANT1
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
&
LICEN D CONTRACTORS DECLARATION
TEMP. POLE 30.00
PAID
I hereby affirm that I am licensed under provisions of Chapter 9
N11 DATE
(commencing with Section 7000) of Division 3 of the Business and
"'V2 .. ... 7
Professions Code d license is in full far W;�ff�cj q
icenx lass,4� Lic. Number
Date Contractor
BLDG. ELECT. I
PLC. MECH.
0
MAY 10 1965
PERMIT:*.4
IN FORMATION 5,01-t
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5. Business and ProfessionsVALUATION
Code: Any city or county which requires apermit toconstrucLalter.
improve. demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to rile a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business ..it Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
MISC. - City Ot UUPeFaPER TO ORD
$/FT.
PERMIT ISSUANCE +e..e&
ELEC. CONTR. LIC. ;0�'ELEC.
TOTAL
PERMIT TO
OTY. �'-'PLUMBING PERMIT 1vFEE.1;,
. _ , " �* .. ". ""',
_ 1��n*
TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not ..x than five hundred dollars (S5001.):
ALTER -DRAIN & VENT -WATER (EA.) 5,00
0 1, as owner of the property, or my emplot...swith wages as
their Sale compensation, will do the work, and the Structure I . a not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
-
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve.'
menta are not intended or offered for Sale. If, however, the building
_
F IXTUR ES - PER TRAP 5.00
CL PT. FLOOR AREA
TOTAL ACREAGE
IGAS-EA. SYSTEM -1 INC. 4 OUTLETS 6.00
r improvement is Sold within one year of completion, the came,
builder will have the burden of proving that he did not build or an.RES
prove for purpose of sale.).
0 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
IND CON PB Coma,
E) Cl El 0 1:1
INDUSTRIAL WASTE INTER. 30.00
-
licensed contractors to Construct the project (Sec. 7044, Business
and Professions Code: The Contract.,', License Law does not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
-
LAWN SPRINKLERS -OVER 5 (EA,) 1.00
-
ASSESSORS PARCEL NO.
contracts for such projects with a contractort S) licensed pursuant to
ontractor , s License Law.
the Contractor's
SEWER -SANITARY -STORM ITARY-STOR M EA. 200tt/I 0.00
TRACT NO.
PARCEL NO.
0 Ion exempt under Sec.-, B,&P.C, for this
reason
- _WATER HEATER W/VENT 6.00
Owner Date
5.00
WATER SYSTEM
ACC. GATE
ACC. FILE NO.
WORKERS'COMPENSATION DECLARATION
jWATER TREATING EQUIP. 5.00
1 hereby affirm (hat I have a certificate ofcorimm to 'etf-ins.m.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof IS o T6'VWt.
Policy N o.
• Certified copy is hereby Nmisred.
• Cc iZ� ye Filed with the city inspection division.
ApplicantMISC.-
FIRE SPFIINK
Y E] N
ENERGY T-24
Y E] NQ
REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
__FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.0
TOTALL'C]
COMPENSATION INSURANCE
(This Section need not be completed if the permit is for one
C]
OTY. MECHANICAL PERMIT
FEE SUMMAR'
hundred dollars IS 100) or less.)"
I certify that in the performance of the work for which this per-
mit is issued, I Shall not employ any person in any manner so as to
become subject to the Worke IS Compensat ion Laws of California.
DateApplicantALTER
F-Ex-
BUILDING
OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: if, after making this Certificate
X..emp!ion,
emption,you should become subject to the Workers' Cum pensat ion
APPLIANCE 5.00
r
PLAN CHECK
provisions of the Labor Code, you must forthwith comply.with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=C.F.K) 4.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
-
the performance of the work for which this permit is issued ISec..
3097. Civ.C.).
MICROFILM
HEATING UNIT (TO 10�,000 B.T.U.) 8.00
H EATI NG UN IT (OV ER 100,000 B.T.U.) 9.50
ELECTRIC
cLender's
Leader's Name
Address
I certify that I have read this application and state that the above
information
- correct.
information is correct I agree to comply with all city and county
- ' c
la
ordinances and state �aws relating to building consina lion. and
"d
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER -COMP(3H.P.orI00,000B.T.U.) 6.00
BOILER -COMP (Over 10i BTU) SEE FEE SCH.
MECHANICAL
v I,
emby authanze representatives of this city to enter upon the
I I
above-mentioned property for inspection purposes.
MISC.- REFER TO ORD.
CONST. TAX
(we) agree to Save. indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses WlIJ61L
may in any way accrueagainst said C. y R consequence of the
"�.IApplicant
PER 10.001
MIT ISSUANCE
MECH, CONT, LIC. NO.
MECH.
__T6TAL1.
graniii thispc it.
I I . It
St a ri`llri�u�Mr Date
OFFICE CUVY