C 5047 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
P2UMBER
BUI LDI NO PROJECT IDENTI FIC' ON APPLICATION & PL AIT
Lr
AD.QRFSS 5047
ApORF55
0001910101 N. DeAnza Bld BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
en
NAME
.�( •1 - 'ar`- „ay}t '�: CH ECK VALIDATION
NAME y6'�f1/2/f p✓}Lh 408/ QTY ELECTRIC PERMIT ,, FEE:
PHONS280-6400
CONrRAcroR's
UT
LETS-SWITCHES-RECEP 5.00/1.00
NAME C16-26170
S&M Sprinkler COr NO LIGHTING FIXTURES 5.00/1.00
IONTRA TOR pPLIANCES-RESIDENTIAL 4.00
ADORE ewood City,CA
_ PHONE PANELS 5.00 DATE OF APPLICATION j
ARCHrt C SIGNS 6.00 PLAN CHECK FEE P.C.NO. {7!(
OR
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ARCH.OR ENG. 500 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH. i
ADDRESS
SERVICE CHANGE 10.00
Woo LICENSED CONTRACTORS DECLARATION WAS
U- I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
as wA. (commencing with Section 7000)of Division 3 of the Business and SLOG. I ELECT. I PLG. I MECH.
InProfessions Coe.lr8 my license is in full force2%e(f@7MV8
❑ El 1:1 ❑
Z= 0 License Class ll.• OO Lic.Number L01 -
N H j Date �,r�B7L85 Contractor�S�Td�4say.' nk er
T :.. PERMIT
",INFORM ?'
a: m OWNER-BUILDER DECLARATION -_ "',INFORMATION;.''
A. N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
Y P VALUATION S/FT.
LL 0 A Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requiresa permit to construct.alter. 39 761• .
w ¢ improve,demolish,or repair any Structure,prior to its issuance,also ELEC:CONTR, LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
W$ he is licensed pursuant to the provisions of the Contractor's License , - ;, .;>r,. s,+y , install
zi Law.(Chapter 9(commencing with Section 7000)of Division 3 of the " " '"
a Businessand Professions Code)or that he isexempt therefrom and QTY. PLUMBING PERMIT, _ FEE'
r $ the basis for the alleged exemption.Any violation o-Seclion 7031.5 °�' �' T- '+�.:.
5PESTS.
by any applicant for a permit subjects the appliwnttoacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages as ISACK 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-FLOOR,ROOF,AREA,COND. 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 g6 FT,FLOOR AREA TOTALACREAGE i
himself or through his own employees,provided that such improve-
allarenot intended or offered for sale,If,however.the building GAS-EA.SYSTEM-I1NC.4OUTLETS 4.00
1. or improvement is Sold within one year of completion,the owner- I
builder will have the burden ofproving that he did not build or on. GAS-EA.SYSTEM-OVER 4(EA.) 1.00 RES ]NO BUILDING
USEPB Other
CONprove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ El El C) 11licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 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 forsuch projects with a contractoos)licensed pursuant to
the Contractor's License Law. :R-SANITARY EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner NPERMIT
STEM 4.00 ACC.GATE ACC.FILE NO.
WORKERS'COAIPENSATION DECLARATION EATING EQUIP. 4.00
I hereby affirm that I have a cerllicau:of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy t roof(Sec.3800,Lab.C.).
Policy Lb ompanY um., yi#_�I -
Q ❑ Geif.-M capyis hereby Yrnls a FIRE SPRINK ENERGY 744
Z Z XI Certifie copy u filed wi a city inspection division. REFER TO ORD.
Q Applicant �17 ^- Y ❑ N� Y ❑ N❑
' may CERTIFICATE OF EXEMPTION FROM s1 RKF:RS' SUANCE 6.00 PLooD ZONE A.L.u.c.
LU >_ COMPENSATION INSURANCE PLG.CONTFL LIC.NO. PLG.
0' 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
0 Z hundred dollars t S 100)or less.) - - ^r '
U O I certify that in the performance of the work for which this per- QTV MECHANICAL PERMIT FEE'- ,FEE SUMMARY'
IL F mit is issued.I shall not employ any person in any manner so as to
Ubecome subject to the Workers Compensation Laws of California. BUILDING
C• w Date Applicant ALTER OR ADD TO MECH. 4.00 2 36
} Us NOTICE TO APPLICANT: IE after making this Cerlif icute of Ex-
CHECK Z eruption,you should become subject to the Workeri Compensation APPLIANCE 4.00 PLAN
provisions of the Labor Code, you must forthwith comply with FEE 154• 0
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(70 IOMO C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1 C.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 ISec. HEATING UNIT(70,100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.CJ.
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lenders Address
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
• information is correct.1 agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction. and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep Isarmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 300 CONST.TAX
may in any way accrue against said City in consequence of tile .
e O
gra ng of this permit. MECH.CONT. LIC.NO. MECH. t
_� TOTAL TOTAL-t-,,.. A�•
Signature of ApplicantlCo m for Vale
OFFICE COPY