6609APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
6609
BUILDING r
ADDRESS 1"2..�� �L.L7SSC.••.
'7 SG J C7
OWNER'S
rvame �x
(AL (1xl2 PHONE 21 l-`1453
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NAME CONTRACTORs
NAME t-
K-Sa O-Yt YS G ��L2UxCcc LIC. No,'A\`�l1°1
UTLETS- SWITCHES -RECEP 5.00/1.00
� LIGHTING FIXTURES 5.00/1.00
Boo F SS hnT,Ys-w (Li15)
APPLIANCES -RESIDENTIAL 4.00
PANELS - 5.00
1 `ACTOR'S
' \h.] NO�JAC-� a'Nt PRONL967 -�Dyu.
DATE OF APPLICATION
ARCHITECTSIGNS
OR
ENGINEER
LIC.No.
6'.BD
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.
ADDRESS
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
ZIP
/�
'
APPLICANT's
ADDRess
5 0\,^e_
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CON'fRACfORS DECLARATION
v� d rs
ed i`i1 df�d
1 hereby allinn that 1 am licensed under provisions.1 Cllapler 9
(commencing with Section 7000) of Division 3 - the Business anJ
I'ro N,sions C'odq, a 1 my UceTu is in full force and elfecl.
License Class Lie. Number L{ s VN.
ISSUANCE DATE
BLDG.
❑
I ELECT. I
❑
PLG. MECH.
❑ ❑
Oa10-L.-�.(�_fyal Contractor V_.4.L.H6--r-
geR-�tces
FP N9 I S .. �_3 g 5:
BUILDING.PERMIT,
OW NI'. R-UUILIJIiR DECLARATION
I hereby allinn that I am exempt 31.5 the Contractor's License
CLaw ode:torthe Anycitylowjngrcywhicheeuires S Permit 1. anddtrufessjons
permit lumnsua ce, alsq
Code: Any city of coaaty which structure,
IIIIprI1Ve, IICBOIILII, or repair any slrllQnrl-, pr1D! l0 ILS ISSYdRCI`, 815(1
'i!11 " ?'
INFORMATION;,
MISC.- REFER _ORD
VALUATION $/FT.
I
YJ GG O
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO.
ELEC.
requires the applicant for such permit to file 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
leconess and Professions Code) or that he is exempt therefrom and
'he basis for the alleged exemption. Any violation Of St,etion 7031.5
TOTAL
PERMIT TO
-
QTY. PLUMBING PERMIT 'FEE
STORIES
TYPE CONSTR.
ALTER -DRAIN & VENT -WATER (EA.)4.00
by any applicant for a permit Subjects the applicant too civil penalty
o1not mom than five hundred dollars ($500).):
❑ 1, as owner of (be property, or my employees with wagesas
will do the work, and the structure is not
'heir sole cum intended
intended Or offered for ole (Sec. 7144, Business and Professions
BACK FLOW PROTECT. DEVICE 2.00
DEC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
Code: The Contractor s License Law does not apply to an owner of
properly who builds or improves thereon, and who does such work
FIXTURES - PER TRAP 4.00
50. FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such nintended improve-
agents are ,of innded .,offend for sole. IL boweveq the building
^�n
9-1GO
GAS - EA. SYSTEM -9 INCA OUTLETS 4.00
or improvement is add 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.).RES
O 1, as owner of the property, am exclusively contracting with
licensed contractor, to construct (lie Project (Sec. 7044, Business
GAS - EA. SYSTEM -OVER 4 IEA.) 1.00
BUILDING USE
IND CON PB Other
13�❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
and Professions Codc: The Contractor's License Law dour not apply
o builds or improves Fhcrron, and who
property'u an owner nl' property who builds
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
contracts Comoraor5u LiceneeLwi'hamntra<toAsl licensed pursuant to
rof ,.' Law.
the tram molls s h projects
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACTNO.
PARCEL NO.
WATER HEATER W/VENT 4.00
❑ lam exempt under Seo. ,B.&I'.C. I'm this
reason
Owner Late
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WORK E RS'COM PENSATION DECLARATION
WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate OFemsellt tO self -insure,
or a certificate of Workers' Compensation InsuraTnce, or a certified
copythereof(Sec. 38.0.�0! Lab C 1. l05'-jx L.21^
Policy Nn.IS-6S Otm1lra •
❑ Certified copy is hereby I...jibed. r
y/. Cerlifi �'�`'p�y ris Filed Will, the city inspecmn division.
Applicant p x.� G.,.a :.�t7-_- �
ZONING
ENG. SITE NO.
FIRE SPRINK
Y ❑ No
ENERGY T-24
Y ❑ N❑
MISC.- REFER TO ORD.
ISSUANCE 6.00
FLOODZONE
A.L.u.C.
CIiRTIPICA'I'IS UP EXEMPTION RR(IM WORKERS'PERMIT
PLG.CONTR. LIC. NO.
PLG.
TOTAL
('Phis section need not beT`ompleteON d ifthe permit is for one
Y❑ NE]Y
❑ N
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY "
hundred dollars (S 1Offer Tess.)
1 certify that in the performance of the work for which this per-
rail is issued, I shall not employ ally person in any manner so as to
becomo suhjen to the Workers'Conlpens.tmn Laws of Cabicaim.
Dale Applicant
NO I'ICI: TO APPIACANT'. If, alter making this Certificate, of Ex-
emption, you should become subject to the Workers Compensation
provisions of the Labor Code, you must forthwith comply with
such pOwismas or tlus permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
BUILDING
/
e%(p
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10SMC.F.M.) 3.00
AIR HANDLING UNIT(OVER 10=C.F.M.)5.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
I hereby alfinn'tict (here is a construction lending agency for
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 IO VER 100,000 B.T.U.P.50
ELECTRIC
Lenders Name
Lender's Address
VENTILATION FAN (SINGLE) 3.00
PLUMBING
I certify that l leave read this application and slate that the above
information is correct. I agree to comply with all city and county
rdinances and stale laws relating to building construction, and
BOILER- COMP(3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Ovar 100,000 BTU)SEE FEE SCH.
MECHANICAL
hereby auth.rue representatives of (his city to cater .,on 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 against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. N0.
MECH.
TOTAL
TOTAL
�r'f
s
grant of is permit.
C.. I
Signal.% ofA licam/Co !actor to
OFFICECOPY