4225APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
. BUILDING PROJECT IDENTI FICATION
'. APPLICATION &PERMIT_
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
4225
SmLOINc
ADDRESS / Al'
O 5 .✓ A
0.40S..3
w ER'S
NAME
�o�aLD /�/iL PHONE
_ _ _
-
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
-
CONTRACTORS
N�""E
- SWITCHES - RECEP� 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
rOUTLETS
X A G6E( uc. No.3$3S(,-
,
oONTRACTOR'S i-
ADDRESS �O 5 J -G
APPLIANCES - RESIDENTIAL 4.00
JE- PHONE Gly G2S3
PANELS 5.00
_
DATE OF APPLICATION
ARCHITECT
on
ENGINEER
LIC. No.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH , OF ADDRESS ENG.
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
ZIP
c
APPLICANT s
API)RE
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
J
LICENSED CONTRACTORS DECLARA'[ION
/ j4,SS 3,g
1 Immhy affirm that I am licensed under provisimis of Chapter')
(commencing with Section 7000) of Division 3 of the Business :uul
Licenssians Code, J my license is in full fort ff •
Date i6 2L% Lic. Number C.
ICnntmd`
DwcMISC.—
ISSUANCE DATE
BLDG.
❑
ELECT.
k
PLG. MECH.
❑ ❑
_
�
owNENER-BOILnEIL1K1F
I hereby affirm that I am'exempt from the Contractors Licrnsc
Lawlorthefollowingreasoa(Sec 7031.5, Businessand Professions
Code Any city or county which requires a permit to construct, alter,
BUILDING PERMIT
INFORMATION
REFER TO ORD
PERMIT ISSUANCE 6.00
VA Luan ON
S/FT-
ELEC. CONTE. LIC. NO.
ELEC,
TOTAL
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to filet signed statement that
he is licensed pursuant to the provisions of the Contractors License
Law Chapter 9 f commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he isexcnipt tllerefronl and
PERMIT TO
XL�
G -
QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant ma civil penalty
of not more them five hundred dollars 155001.1:
STORIES
TYPE CONSTR,
ALTER -DRAIN B(VENT-WATER (EA.) q,00
❑ L as owner of the property, or my employees with wagaa ax
sole compensation. will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2,00
occ. GROUP
EES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Cade: The Contractor's License Law does not amply to an owner of
FIXTURES - PER TRAP 4.00
GAS - EA.SYSTEM - I INC.4 OUTLETS 4.00
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsurenotintendedorofferedforsale, If, however, the building
so. FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner-
builder will have tie burden of proving that he did not build or it,, -.
r-
prove 11,a,owrcrot purpose of sale.).
❑ I- us owner of the property, um exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA) 1.00
BUILDING USE
RES NO CON PB Other
❑ ❑ D ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
licensed contractors m construct the project (See 7044, Bus'inc<s
and Professions Code: Tile Contractor's License Law docs not apply
to an owner of property who builds or improves thereon, and who
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
Contracts for such projects with a contractoto licensed Pursuant to
the Contractors License law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
rea ❑ I and exempt under Sec. , B.BI'.C. for this
WATER HEATER W/VENT 4,00
Dare Uwnor
WATER SYSTEM 4.00
ACC. DATE
ACG _FILE NO.
WATER TREATING EQUIP. .4.00
WORKERS'CONI PENSA[ION DECLARAT ION
I hereby affirm that I have a certiticmc of consent vnelf-innurc.
certificateor a of Workeri Compensation Insurance, ora citifiedENG.
c
ZONING
SITE NO.
copy thereof 3800, Lah.CJ,z _A-0—
1' No. Cont .... ly �V /Slf_i
FIRE SPRINK
Y E] NE]
ENERGY T 24
Y E] NE]
C tificil y u hereby to niched.
❑ Certified oily is tilt'y�,'Sth }r By ispectmo division.
Applicant_ y �(
MISC. - REFER TO ORD.
CI`R1IFICATE 017 EXIMPHON FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.LUC.
CONiPIFNSATION INSURANCE
( I'his section need not be coni Pleted it the permit is for one
PLG. CONTE. LIC. N0.
TOTAL
V N
Y N
hundred dollars IS 100) or Ices.)
I certify that in the performance of the work for which this per-
alit is issued, I shall not employ any person many manner so ars to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
I et Inc.Lhjeet to the Workcrs'Comper Rdiml Laws of Calionnia.
ALTER OR ADD TO MECH. 4.00
Date Applicant
NOTICE TO APPLICAK'I': If, after making this Certificate of E,.
BUILDING
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
PLAN CHECK
FEE
emption, you Should become subject to the Workeri Compensation
provisions of the Labor Code, you Durst forthwitt comply with
such provisions or this pennit shall be devilled revoked
AIR HANDLING UNIT(OVER 10)DODC.F.M.) 5.00
SEISMIC FEE
CONST RUC'T'ION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the pmfnnaance of the work for which this permit is issued (Sec.
3097, Civ.C.).
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
HEATING UN IT 100,000 B.T.U.17.50
ELECTRIC
6°v
I certify that 1 have lead this application ad, Stam that the above
V ENTI LATION FAN (SINGLE) 3.00
inlimnoaten is correct. I agree to comply with all city' anJ n Imy'
ordinances and state laws relating to building eunstructinit an J
PLUMBING
BOILER-COMPI3H.P.Or100,000B.T.U.) 4.00
BOILER_COMP IOvar 100,000 BTul SEE FEE SCH.
MECHANICAL
-
hereby authodre reprewntat fives of this city R ertler inion tilt
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenus which
may in u Y way accrue against said :ily in consequence of the
MISC.- REFER TO ORD.
PERMIT ISSUANCE 3.00
CONST. TAX
grantin this permit.MECH.
CONT. LIQ NO.
MECH.
TOTAL
TOTAL
Signature ApplieptillContraclor Dale
OFFICE COPY Z"