6414Ab
0
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER- a
6414
BUILDING
AOOREss
% R RL0A1E_-
.NEG '6
NAME
YXON E /p -fid
ELECTRIC PERMIT FEE
-
PLAN CHECK VALIDATION
CONTRACDRS
UTLETS- SWITCHES -RECEP 5.00/1.00
1>6 LIc.ND.37-
LIGHTING FIXTURES 5.00/1.00
C-ONTRACTOR's /S
ADDREa
APPLIANCES, 4.00
PANELS 5.00
/_ q
Ilglpqg &-44 PHONE S/- 33�
DATE OF APPLICATION
owpM1iEOT -
ENGINEER
• uc. No.
SIGNS 6,00
PLAN CHECK FEEP.C. NO.
-
SIGNS TRANS. 3.00
Doo ESS ENC.. -
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OWPOLE INS. .15.00
,ZIP
'
APPLICANT ADDRESS
A
MOTORS SEE FEE SCH.
SERVICECHANGE 10.00 -
_
LICENSED CONTRACTORS DECLARATION
pp
-vOQ
L
1 hereby uffiml that I wn licensed under provisions of Chapter I
(com orscing with Section 7000) of Division 3 of the Business and
Professions '
C9 uppiyy�ll y license is in full f `{ c
Licenses-6�dLieumhe
Nmnt�IC��
ISSUANCE DATE
BLDG. ELECT.
❑
PLG. MECH.
❑ ❑
Dote.✓ Coral R
.❑
BUIL ��gqMIT
INFO PION
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Sec. 7031.S. Businessand Prof4zsiuns
Code: Any cityor rounty which Stnie eta pemsiuomnsloores, ter;
u,uH..dcmoluh,. repairany smit to also
MISC.- REFER TO ORD
v I N
_s 1 O_
tJ a' v 1 (1
SIFT.
A
Y
PERMIT ISSUANCE 6.00
ELEC. CONTE. ❑C. NO.
ELEC
I Cilepoorsigned
hquires the applicant For such permit ns lite a signed st HH'i Li ethatnse
he "v licensed pursuant m the pnwisions of the Contrucwr's License
TOTAL
tui TO
J ) F`sa...-ae.
OTY. PLUMBING PERMIT FEE
Law (Chapter 9(cummencing with Seel ion 70000nf Division 3 oflhc
Business and Profwlons Code) or that he is exempt therefrom and
�G �'.� "�4t ono
�STORIE�S- o
C�d
TYPE CONSTR.
Ab
the hasudor the alleged exemption. Any violation of Seetion7031.5
by anyS,plicunt for u peonit subjects the a pplicautto.er,ii,emilty
of not mom than five hundred dollars (5500):):
- ALTER -DRAIN & VENT -WATER IEA.14.00
O I, as owner of the properly, or my employees with wages as
their sole compensation, will do the work, and the swctu¢ iS not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
PES. UNITS '
DRAINS -FLOOR, ROOF, AREA,COND. 4.00 -
intended or offered for sale (Sce. 7044, BusinessandProfession
Code: The COntmdor s License law don noPapply loan owner of
FIXTURES - PER TRAP 4.00
50. FT' FLOOR AREA
OTALACREAGE
property who builds or improves thereon, and who docs such work
hovels' or through his own employees, provided that such improve-
mentsare not intended or offered for sale. ll, however, the building
GAS - EA. SYSTEM -1,INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that h e did not build or ins
prove lar purpore of sale.). -
C1 1.
I, as owner of the property, am exclusively contracting with
- . ..
GAS EASYSTEM -OVER 4 (EA) 100
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.D0
ASSESSORS PARCEL NO.
licensed contractors to comtruct the project (See. 7044, Business
and Professions Code: The Contraewis License Law dues not apply
to an owner of property who builds or improves thereon. and who
contracts for such pursuant to
the Contractor's su h projects
Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACTNO.
PARCEL NO.
❑ 1 am exemP.l under Sec. ,BAP.C. for this
meson
'
WATER HEATER W/VENT 4,00
Owm;r Date
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
wORKERS'COMPensnTION DECLARATION
I hen•by affirm that I have a ec"ifleate of consent to self-inuoe,
or a-certificale of Workeri Compensatian Insurance, or certir.d
ZONING
ENG. SITE NO.
e b C )
copy merepf l$yil�ilab r.). e_a.AG.
Policy � mi8.411Rp Z /AS -
.
FIRESPRINK
Y ❑ N❑
ENERGYT24
Y ❑ N❑
-n
❑ Certifc co yah by If shed.
❑ -Certified py �Icd-Jy1Ih the city insjxaion Aivision.
APPlicanI -
MISC.- REFER TO ORD.
CER'I'IIICA'TI- OF ExEmPT1oN FROM WORKERS'
PERMIT ISSUANCE - 6.00
FLOOD ZONE,
A:L.UG,
. COMPENSATION INSURANCE
(Thu section need not he completed if the permit is for one
PLG. CONTE. LIC. NO.
PLG.
TOTAL
YE] N❑
Y ❑ N❑
hundred dull. IS 100) or less.)
I certify that in the pe,fofmance of the work for which this per -Qtr
mil is issued, I shall not employ any person in any manner so as to
MECHANICAL PERMIT FEE
FEE SUMMARY
•.
BUILDING
/ o
'become subject to the Workcri Compensation Laws of Califomix.
Date - Applicant.'
ALTER OR ADD TO MECH. q -W
NO ICI, TO APPLICANT: 1L after making this Certificate of Ex-
emption, you should become subject to the Workeri Compensation
APPLIANCE 4.00
PLAN CHECK
pruvisians M the Lala, Code, you most forthwith comply with
such provisions or this pe,mil shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=C.F.NL) 3.06
AIR HANDLING UNIT(OVER10MC,EM.)5.00
SEISMIC FEE
d�
. CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work fin which this permit u iswed (See.
3097, C;v.C.1.
MICROFILM
HEATING UNIT (TO 100,000 B.T:U.) 4.00
Lenders Name
Lender's Address
'HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
I certify (hat I have read this application and stain that the above
VENTILATION FAN (SINGLE) 3.00
information n correct. 1 agree (o comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
'
BOILER- CONP(3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP IOser1W,000BTUISEEFEESCH.
MECHANICAL
hereby ausboriae representatives of this city to enter upon the
ubove.mcntioned property for inspection purposes.
MISC. - - REFER TO ORD.
-
(We) agree to save, indemnify ..it kccp innul. the City of
Cupertino against liabilities, judgments, costs and expenses whish
may in any way c e against aid City in consequence of the
CONST. TAX
PERMIT ISSUANCE300
.
lU'anfingo hisr
• S
MECH.CONT. LIC. NO.
MECH.
TOTAL
TOTAL
-
SiArlat re, A •
lican ontracmr Dalc v
OFFICE COPY