66250
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
6625
nool°ess �ulrc 107/
D8C�eeIC BLVD
OWNER'S
NAME
FINWgtIJ /}s$'J<. PHONE
IW, , -vs s�S.M"fF'%'� ��, A
�x'x �ts��fiLECTRICP,ERMIT ,f,LLrS j+pEBk
atP
PLAN CHECK VALIDATION
eom¢RAcrORs
UTLETS- SWITCHES -RECEP 5.00/1.00
SQ CDD /✓4e- uc. NO.
LIGHTING FIXTURES 5.00/1.00
DATE OF APPLICATION
CONTRACTOR'S Y ���u� r
AooREss 4/ 'J %� «4/S �E�/
�,C. y /�j` PROry E��7-S//1
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
ARCHITECTSIGNS
OR
ENGINEER
uc. Na.
S.00
PLAN CHECK FEE C. NO.
SIGNS TRANS. 3.00
ADDRESS Ervc'
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
ZIP
1D
J ��9
/yJ
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH. -
SERVICE CHANGE 10.00
LICENSE I) CON "TRACTORS DECLARATION
(` ^ ^
I hereby affirm That I in licensed under provisions of Chapter 9
ISSUANC /DATE
(commencing with Section 7000) of Division 3 of the Business ataBLDG.
Lwvase ons Code, an my licanm is in full fore • aT IIcSt.
License Class-L'=_!_(� Lie. Nu
ELECT, PLG. MECH.
❑. ❑ ❑ ❑
bify 51
Date �1 Con
a�RA'II
.., BUIkDINO P,ERMIL,yry,""y:,
•' : 1111FORMATION : ;e(a 4
I�I� Nti
OWNT:R-BUILDS �
I (tar tine toilo that I um exempt Irons The Contractor's Pr License
Lawlor GTefollowingremon.(Sec.uires a,ermit tocndtrut.aluns-PERMIT
Code: Any city or county which requires permit to construct. iter,
improve, demolish, ur repair any turn toff prior m its atom IX, A.
he WfeS ns applicant for such revisit is IIIc a (Cont statement that
he is licensed pursuant n the provisions of the Contractor's License
Law (Chapter 9lcommencing with Section 70001of Division3 at the
Business and Professions Cadet or that he is exempt therefrom and
the basis for alleged exemption. Any violation of Section 7031.5
MISC. - REFER TO ORD
ISSUANCE 5.00
VALUATION
/
E/FT.
ELEC. CONTR. LIC. NO.
TOTAL
TOTAL
PERMIT TO
L�
/ ilec- f�a /�KLi]784
O7•Y: .: t,: ,� -0LUMBINO- PERMIT FEETo
STORIES
TYPE CONSTR.
by any applicant for a permit subjects the applicant ma civil penalty
of not more Than five hundred dollars 155001.1:
ALTER -DRAIN -WATER (EA.) 4.00
❑ h 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: '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-
rentsarenmintended or offered for sale. If, however. the building
FIXTURES - PER TRAP 4.00
SO. FT, FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -1 INC.4 OUTLETS 4.00
r improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or im-
proseforpdroc.alsale.).
❑ 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB ome,
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construct the project (See. 7044, Business
and Profession, Cade: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
LAWN SPRINKLERS - 1 INC 5 V.8. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1,00
ASSESSORS PARCEL NO.
contracts for such projects with a cunlractonsl licensed pursuant to
the Contractor', License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO,
PARCEL NO.
❑ lam axempt under Stc. ,B.&P.C. fir this
al.,
WATER HEATER W/VENT 4,00
Owner Date
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to sel6insure'
or a certifteate of Workers Compensation Insurane•, or a cgrtified
copy thereof (Sec. 3800, L' C.j. r1IHPC�Z./1;I)
Policy N'o:Q Tj `�-.�1-11>, (/L`
❑ Certified ca r (sshherchy l-ur ush . '" - '
Cervi y is til with t r y nspection division.
plicant
ZONING
ENG. SITE NO.
FIRE SPRINK
Y [3N El
ENERGY T 24
1:1 No
MISC.- REFER TO ORD.
CERI'IFICATIi OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.O.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
(This mclion need not be completed if the permit is for one
Y ❑ N❑
Y ❑ N❑
,. P �- ,•„
GTV. 1• y '.°' MECHANICAL PeRM1T-4-`s '' "FEET
.. i
•• - -
tLan"C'FEE-BUMMARVv'.`-'u�'-J^-!
humhed dollars IS 1001 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 wM1icct to the Workers' Compensation Laws of California.
Date Applicant
BUILDING
) _
ALTER OR ADD TO MECH. q,00
NOTICE TO APPLICANT: IL after making this Certificate of Ex-
emption, you should became subject to the WorkersCompensation
APPLIANCE 4.00
PLAN CHECK
provisions of the Labor Code• you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10DWC.F.M.) 3.00
FEE
-•�
-y
AIR HANDLING UNIT (OVER 10=C.F.M.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
The performance of the work for which this permit is issued (Sec.
3097, Civ.C.l.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Address
I certify that I have read this application and state that the above
VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county
ordinances and slate laws relating to building construction, and
PLUMBING
BOILER -COMPO H.P. Or 100,000 B.T.U.) 4.00
BOILER -COMP 01100,000 BTUI SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
abovo-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save,,indemnify and keep harmless the City of
Cupertino against (Tab' ;lies, judgments, rosts and expenses which
may in any way ac a against syid City in conspyuence of the
PERMIT ISSUANCE 3.00
granting of this r d///LJ/ls 'aneyon)/v p
MECH. CONT. LIC. NO.
MECH. TOTAL
/.': TOTAL'
s,_.":
,
Signature of Applicant/Contractor Dafe
OFFICECOPY