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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN -'ONLY
BUILDING PROJECT IDENTIFICATION7
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
�--PERMIT NUMBER
��f`
BUILDING
MtO iSTEverN.S CK�C�
OWNER'S CIP/T f2p.�/{/
67,/
PLAN CHECK VALIDATION
NAME VV,11yIq�}l}L. ,
OTY. ELECTRIC PERMIT FEE
{.LLi18J�PG(�jy�LF♦ PHONE
CONTRACTOR
NAME
NOME /I/I/ A
ICOM He �%�l�lLA111C, NO 40862
OUTLETS - SWITCHES -RECEP 5.00/1,00
DATE: OF APPLICATION
LIGHTING FIXTURES 5.00/1.00
ADDHEScTons
CONTR C5
571'N '-' 7Sq AWOSHONE
APPLIANCES - RESIDENTIAL
PANELS 5.00
ARCHITECTSIGN$
OR
ENGINEER
LIc. NO.
6.OD
PLAN CHECK FEE
G P.C. NO.
SIGNS TRANS. 3.00
ADDRESS END '
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
ZIP
i
APPLICANTSMOTORS
ADDRESS
57/ N.7 RN joky&r
SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby aflion that 1 am licensed under provisions of Chapter 9
(commencing with Station 7000) of Division 3 of the Rusiness :ted
Pod! ... hins Cod", I Peens, is in full fame A c
Jp`o•`k22
,scoria, Cl sem.=Gf„2 Lia Nanlber
ISSUANCE DATE
BLDG.
❑
ELECT.
❑
PLG. MECH.
❑
Bala-6_b�Cantractar
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARA'I ION
I heron 1 am exempt froe. m I hl•Camral:l ofsfessi fns
y efl trod hollowing
ity or count which requirsaper sit tocodProfessions
Coda.e: AnIIIy
Code: Any city or county which requires, permit tocol construct, .also
Improve, dema115I1, or repair any 5t(VCtUIC, prior IV Its lSSVa11CC, also
MISC.- REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 6.00
ELEC CONTE: LIC. NO.
ELEC.'.'
requires tire applicant for such permit to file a signed statement that
he isCaps licensed pursuant to the provisions of the Contr:remr's License
of Division 3 of the
Law (Chapter 9 (commencing with Section is exempt
Business and Professions Code) or that he is exempt therefrom and
-
TOTAL
PERM I 0
' ,. , I
C'///^�•I/'
DTV. PLUMBING PERMIT FEE
STORIES
TYPE CONSr.
the basis for the alleged exemption. Any violation oto acliun 7035
.by IRG5feet appliculitfor e permit subjects tS00R.Jiwnuoacivil penalty
.feet more than five hundred dollars (5500).):
ALTER-DRAIN-WATER(EA.)4.00
❑ I, as owner of the property, or my employees with wages as
their Side 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, Iladocss and Professions
Code: *1 lie Contractor's License Law does not apply to .n owner of
FIXTURES - PER TRAP 4.00
SO, FT, FLOOR AREA
TOTALACREAGE
properly who builds Or Improves thereon, and who does such work
himself or through his own employees, providedThatsuch improve-
mmotsarenotintendedorofferedforsale.lf, however, lite building
GAS - EA. SYSTEM - I INC. 4 OUTLETS 4.00
RI improvement is sold within one year of completion, the owner-
hit der will have the burden o'proving that he did not build or int-
prove for purpose of sale.,
❑' I, .s owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
I N DUSTR A L W ASTE INTER. 20.00
licensed contractors to construct the project (Sec 7044. Business
and professions Code: The Contractor's License Law does riot apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects will, a contractods) licensed pursuant to
lire Contractors License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ 1 am exempt under Sec.-. B.&P.C. far Ibis
reason'
WATER HEATER W/VENT 4.00
(jwnm Date
WATER SYSTEM 4,00
ACC. DATE
ACC. FILE NO.
WORK ERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 4.00
-
I bercby affirm that I have a cvoific,v ofconsenItocell-insure,
or a certificate of Workers' Compens.lion Insurance, or a certified
ZONING
ENG. SITE N0.
copy Iheo (Sec, 380 Co Lub.Cy„,x' TH 25/zUUg-
policy Nn. Con,[ Y
❑ Certified co ris ercbyfu di-
❑ Cerli'• s flc , m c i19ion Division.
Applicant
-
FIRE FIRE SPRINK
Y❑ N❑
ENERGY T-24
Y❑ N❑
MISC.- REFER TO ORD.
CER1'IICA'[ 17 OF EXEMPTION FROM WORK E. RS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLG. CONTE. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
(Phis section need not be completed if the penin is for one
Y ❑ N❑
Y E] IN E]
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
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
BUILDING
become subject to the Workers' Compensation Laws of California
Dale Applicant
'1'0
ALTER OR ADD TO MECH. 4.00
NO1'ICIi APPLICANT: If, after making this Certificate of Ex-
anption, you should become subject to the Workers' Compemation
APPLIANCE 4.00
PLAN CHECK
provisions of the Labor Code, you most forthwith comply with
such previsions or this permit shall be decnmd revoked.
FEE
2 AIR HANDLING UNIT (TO lOJAOGF.M.) 3.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00
SEISMIC FEE
CONSTRUCTION 1.1'NDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the perturmance of the work for which this permit is issued (Sec.
3097. Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 T.U.)7.50
B.
ELECTRIC
Louder', Name
Lender', Name
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 state laws relating to building construction, and
PLUMBING
_
BOILER -COMP 3H. P. or 100,000 B.T.U.1 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE.§CH.
MECHANICAL
`7
/ dql
V
hcrchy aathurim representatives of this city 10 enter upon the
above-mentioned property for inspection purposes
(we) agree to save, indemnify and keep harmless the City of
MISC. -(Z.) cN REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which
....y in any way accrue against said City in consequence of the
CONST, TAX
PERMIT ISSUANCE 300 - L.
.
gmnlio This ""I
j�AA� 3-4-65
MECH. CONT. LIG NO.
MECH.
TOTAL, �Jtl
TOTAL
Sig-nal�ie`off Apppbcan CVntrctor Date
INSPECTOR COPY