2915 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
9UI LDING PROJECT IDENTIFICATION PERMIT NUMBER -
APPLICATION & PERMIT
BUILDING _ 2915
ADDRESS, -
22305 Carta Blanca BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S - - - PLAN _ 'DATION
NAME - OTY. ELECTRIC PERMIT FEE
Elliott Nohr PHONE 733-891+9
NAME ncrDRs - UTLETS-SWITCHES-RECEP 5.00/1.00 SEP 2 0 "19$3 '
Atlas Furnace Co. C.NO. 137803 LIGHTING FIXTURES 5.00/1.00
DDRRACrOR's ' PPLIANCES-RESIDENTIAL 4.00 City of Cupertino
ADDRESS - n
155 Commercial,_ PHONE 739-0516 PANELS 5.00 DATE OF APPLICATION
ARCHITECT , SIGNS g�D PLAN CHECK FEE P.C.NO.
0.ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ADDRESS ENG. - SPECIAL CIRCUIT 5.00 PCTION
•
ZIP EMP.METER OR POLE INS, 15.00
APPLICANTS
ADDRESS _ . MOTORS SEE FEE SCH. )C)
ADDRESS
SERVICE CHANGE 10.00
_
r
02 LICENSED CONTRACTORS DECLARATION
0 i w 1 hereby affirm (hut I am licensed under provisions of Chaplet 9 ISS E DATE
a N (commencing with Section 70001 of Division 3 of the Business and BL ECT. PLG. H.
F N z Professions Code,m y license is in full'foryegp�I�f t. ❑ ❑
Z, z N W Licenx ks - Lie.Numbe'419
F u,R J Date O Con.-actor AW.aH
a >< s BUILDING PERM
¢ ¢o i OWNER-BUILDER DECLARATION _ IN FO RMATIO
K ; H. 1 hereby affirm that I am exempt from .he Contractor's.License MISC.- REFER TO OR
m VALUATION $/FT.
F u O j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
0 � Code:Anycityorcounty which requiresa permit tocons.rucl;alter,
le a, ¢a_ ED Improve,demolish,Or repair any structure,prior IO Its IssuarIm also ELEC.CONTR. LIC.NO. ELEC.
C u requires the applicant for such permit to file a signet statement that TOTAL PER IT T
w$m he is licensed pursuant to the provisions of the Contractor's License
ri > Law(Chapter 9(commencingwith Section 7000)of Division 3 of the.
F i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H a the basis for the alleged exemption.Any violation of5ection 7031.5 ORIES TYPE CONSTR.
a ; � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($5000.).
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW'PR PROTECT. DEVICE 2,00 OCC.GROUP 'RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 4.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTALACREAGE
himself or through his own employees�provided that such improve.
meets are not intended of offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or Ho- - E IND CON PB 'Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 2000
❑ 1,as owner of the property,am exclusively contracting with . .
❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS'-1 INC 5 V.B. .5.00 ASSESSORa PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPR INKLERS-OVER 5IEA.) 1,00
contracts for such License
L with a enntruaor(sl licensed pursuant to SEWER-SAN ITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
life Contractor's or such
License Law.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATTON DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy therpq(f SeL.r7$(1Q
Policy No ny mP� ++d Tn R trap -
Q ❑ Certified copy is hereby(urdisheJ. FIRE SPRINK ENERGY T-24
❑ Cerlif'¢�.�p is.ti4n t1s h' qty inspection division.
ZZO Applicant A"uk3 Ptllllti(:� i(l. MISC.- REFER TO ORD. Y ❑ N❑' Y ❑ N❑
.CCN CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE • 6.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
0.Cl (This section need not be completed if the permit Is for one TOTAL Y❑ N❑ v [:] N❑
hundred dollars($100)or less,)
U O I certify that in the performance of the work lit,which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0 y Date ApplicantALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: IL after making this CeRifica.e of Ex-
� ? emp.ion,youslmuldbecomesubjectiothe.Workers'COnlpensution APPLIANCE - 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C7 such provisions or this permit shall be decowd revoked. AIR HANDLING UNIT(TO 10MCF.M.) 3.00
CONSTRUC'T'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11C.F.M.) 5.00 SEISMIC FEE
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(See. MICROFILM
3097,Civ.C.x I HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)7.50
-50
Lender's Address ELECTRIC
I certify that l have read this application andstare that theabove VENTILATION FAN (SINGLE) ' 3.00
information is correct. 1 agree to comply with all city and County PLUMBING
ordinances and state laws relating to building constn'nion, and BOILER-COMP(3 H.P.or 100,000 B.T.U.
) 4.00
hereby authorize representatives o1' this city to elver upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
abovc-mentioned property for inspection pulp oms.
(We) agree to save, milenmify and keep harmless the City of MI R ER O ORD.
Cupertino against liabilities,judgments, costs and expenses which $ A CE 3.00 CONST.TAX
may in.any way accrue against said City in consequence of the
Stan ng of thlspeNil MECH. LIQ NO. CH.
OT" TOTAL /
Signature of Applicant/Contractor pate Atlas, Furnace - 137803 10.50
OFFICE COPY