11269 APPLICANT TO FILL IN INFORMATION WITHIN RED L6NE`J USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON - PERMIT NUMBER
So ILDIND APPLICATION & PERMIT
-y` ADDRESS 11269
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I Sfeo A sTEK CAN£ , , BUILDING-ELECTRICAL-PLUMBING -MECHANICAL I G vn vM
OWNER'S /', PLAN CHECK VALIDATION
. ' NAme 4,D
� (/E-J�,.S tI[OQ QTY. ELECTRIC PERMIT FEE
tC S `1CAr 6 �P DNE /0-/,788
CDAMERACTOR'S OUTLETS-SWITCHES-RECEP 10.00/1.00
CSTM L CTi21C uC No qw&6-7 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S SAN TO-SC APPLIANCES-RESIDENTIAL 4.00
ADDRESS '. /
3075- M/ODD5 W14 'HONE(408 270 72 j PANELS 10.00
DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC NO. ISIGNS TRANS. 3.00
ADDRESS ervc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION'
ZIP TEMP.METER OR POLE INS. 20,00APPLICANTS
^
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
F D o LICIiNSED CONTRACTORS DECLARATION
Re cs Aee7 4 - 6 ATE
.
¢u w I hereby affirm that I am licensed under provisions of Chapter 9 ISS ANCE CE ATE
w< h (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
f., w z Professions Code jun' 'license is in full furcg psMe[feci 5.' ❑ ❑ ❑
0 z w - License Class CJ Lia.Number WOK 6
0 m r w ale Cmllmctor'
Q y 2 J
s ¢w¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
D a D INFORMATION
X ; a y 1 hereby infirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u. D¢ Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
t- - PERMIT ISSUANCE 10.00
iw0E Code:Any city orcourdy which requires a permit to construct,alter
re ¢ O improve,deniolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC NO. ELEC.
i0¢ requires the applicant for such permit to file a signed slatem eel that TOTAL
w m w he is licensed pursuant to the provisions of the Contractor's LicensePERMIT TO
F z i Law.(Chapter 9(commencing with Section 7000)of Division 3 ofthe ELEC A,1Q
i Business and I'rol'essions Code)or that he is exempt lheoefrnn and QTY. PLUMBING PERMIT FEE
¢ H 0 the hasis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ; by any applicant for a permit subjects the applicant toe civil penalty
of not more than five hundred dollars($500)): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT; DEVICE 4.00 OCC.GROUP REB.UNITS
their Sale compensation,will do the work,and the structure is not
intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 `
Code:The Contractor's License Law docs not apply to an owner of
• property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 So.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such inlprove-
meuts are not intended or Offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
budder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 - BUILOING USE
prove for purpose of sale.). RES IND CON PB Onrer
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See.7044,Business • LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contracta ls)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ tum exempt under Sec. ,B.&P.C.Iia Olis WATER HEATER W/VENT 6.00
reason
Owner - _ Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP, '5.00
1 hereby affirm that I have a certificate of consent to self-inane,.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C).
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T$4 ' f
Z 2 ❑ Certified copy is filed with the city inspection division. MISC.- - REFER TO ORD.
0 Applicant Y ❑ N Y ❑ No
� y CERTIFI CATE OF EXEMPTION 17ROM WORKERS' PERMIT ISSUANCE 10.00 FLODD ZONE A.LU.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
0.0 (This section need not be completed if the permit is for one TOTAL v❑ N❑ Y ❑ N❑
hundred dollars($100)or less)
U O I certify that in the performance Of the work for which Otis per: OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL i- mil is issued.I shall not employ any person in any manner so as to
O W bemnte�sub�'est tp�ue Workers'Gxnpe sa on L s fG�lilbr�y`
Ua4_fe�[.(r-dlx Pelicans {iG�. /�.1-0 1[X. ALTER OR ADD TO MECH. 5.00 BUILDING
} N OTICE TO APPLICANT: If,atter making this Cetlificate of F:x-
I. Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONS't'RUCf1ON LENDING AGENCY AIR HANDLING UNIT(OVER IQOWGEM.) 6.00 SEISMIC FEE
I hereby al7irce that there is u construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work lir which this permit is issued fSec. - MICROFILM
3097,Civ.C). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's HEATING UNIT(OVER 100,000 B.T.U.)9.50 (/tr
Lender's NameAddress' - ELECTRIC
. I certify that I have read this applicaliun and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and County PLUMBING
ordinances and state laws relating to building construction, anti BOILER-COMPO H.P.or 100,000 B.T.U.) 6.00
hereby authuriLC.represcntatives of this city 10 enter upon the BOILER-COMP Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(we)=agree to save, indemnify and keep harldeSS slue City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs mW expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence or the
grantin of this permit MECH.CONT. LIQ NO. MECH.
znfiio TOTAL TOTAL
Signature of licunt/Contrato
cr •Date
OFFICE COPY