4484 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - 'E BALL POINT PEN ONLY
I'--- BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BILILOING APPLICATION & PERMIT 44 4
A OGRESS
X 7851 Ee].kxla Drive BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
NAME
x O7V. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
Hail Straka PHONEDcNT255-3249
NAVE OTORs OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
Security Roofing, InQ, 0681LIL LIGHTING FIXTURES 5.00/1.00
nods es
ADDRESS q 15 PPLIANCES-RESIDENTIAL 4.00
G
P. 0• Box 0 P»ONE 591-7663 PANELS 5.00 DATE OF APPLICATION
ARC»RELi Menlo Park 94025 PLAN CHECK FEE P.C.NO.
oR SIGNS 6.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ante. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
O o LICENSED CONTRACTORS DECLARATION Re-Roof
¢ U U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
pTear off old roof and Re-too
w C h (commencing with Section]000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
»w Professions Co �n y license is in full for Rrks �cL - Heavy Shakes. neW va ey , ❑ ❑ ❑ ❑
' 0. - License C. 1. Numbe DO D nail
cute ' Contractor a .11r' O In
Hof
¢ a w Ar OWNER-BUILDER DECLARATION BUILDING PERMIT
o - INFORMATION
ED.. .
;e H 1 hereby affirm trial l am exempt from the Conlrncmr's License VALUATION S/FT.
Law for Ole following reason.(Sec.7031.5,Busmessand Professions 6.00 .[,�Qp
L - g PERMIT ISSUANCE \ / /O
Code'Any city or county which requires a permit to construct,alter,
¢ ¢ Ar p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
wm¢ requires the applicant for such permit to file a signed statement that TOTAL
he Is licensed pursuant to the provisions of the Contractor's License PERMIT TO
se Law(Chapter 9(commencing with Section 7000)of Division 3 of the PQ..00� sE��'
f 4 o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE „
¢r o the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TYPE CONSTR.
c; m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not mute than five hundred dollars($5001.1:
❑ I,as owner of the property,or any employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOORROOFAR EA,CON D. 4.00
Code:The Contractor's License Law does not apply to an owner of , , '
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP - 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
r� himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 4.00
Or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
_ builder will have the burden of proving that Int - .did not build or int-
prove for purpose of sale.). RES IND CON PB Gore,INDUSTRIAL WASTE INTER. 20.00
Cl 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,BusinessLAWN SPRINKLERS 1 INC 5 V.B. 5.00 ASSESSORS PARCEL N0.
and Professions Code:The Contractor's License Law does not apply
l0 an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmctorls)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA. 200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B.&P.C..for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILENO.
WORKERS'COAIPF.NSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of vonsenl to self insure,
or a certificate of Workers'Compensation Insurance•or a certified ZONING ENG.SITE NO.
copy thc,%y� Lab.C.`` yy����,.,,,��
Policy No.k1 mpan Yea-tat-e-llltabl_InBa_
❑ Cettit copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z z7 Certifl• o is'- d why 'the ty,Inspcction'divlslon.
0 Apetir nt .-/1Lsz�f.ti�.,-,. MISC.- REFER TO ORD. Y E] NY 1:1 MCI
�O PERMIT ISSUANCE 6.00
y CE 'IPICATP OP EXEMPTION FROM WORKERS' FLOOD 20NE A.L.u.C.
Lu - COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
'CL cl (This section need net be completed it the Rennll is for One TOTAL Y N Y N
=) 2 hundred dollars($100)or less.)
U O 1 certify that in the performance of lire work for which this Per- O7V MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mil is issued,I shall not employ any person in any manner A)as to
O w become subject to the Workers'Compensation Laws of California.
y Date ApplicantBUILDING
>_ 0 NOTICE TO APPLICANT: If,after making this Certificate of IN. ALTER OR ADD TO MECH. 4.00
F z emption,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK C
Provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1C.F.M.) 5.00 SEISMIC FEE 6-01 hereby affirm thus there is a construction landing agency or EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this per...it is issued(Sec. - MICROFILM
3097,CIv.C.). none HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
information n correct. I agree ti comply b with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-ODMP(3 H.P,or 100,000 B.T.U.) 4.00
hereby aulhorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
4�G.
any way accrue against said City in consequence Of the
MECH.CONT. LIC.NO. MECH.
/ 1O 2 8° TOTAL TOTAL 51.00
re of Applicant/Cnntraet Date -
OFFICE COPY