3635 ;APPLICPN'T TdIFILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
•"' 13UI LDING PROJECT 1 DENTI FICATION PERMIT NUMBER
'ADDRESS Io V. APPLICATION & PERMIT � ��[
CVPE�TIND, CA. BUILDING -ELECTRICAL-PLUMBING-MECHANICAL J
O
R E E - _ - _ _. .
PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
ONE
CONTRACTORS
NAME THF KOLL Co. - UTLETS-SWITCHES•RECEP 5.00/1.00
uc.NO, LIGHTING FIXTURES 5.00/1.00
ADDRESS
165 I • 5 . PPLIANCES-RESIDENTIAL 4.00
CONTRACTORS
/�
SAN J05 E, GA• PHONE -/S�)Z PANELS 5.00 DATE OF APPLICATION
ARCHITECT 3 f"IE5 FO SIGNS 6.00 PLAN CHECK FEE P.C.NO.
��
ua No, - SIGNS TRANS. 3.00
ARCH,OwiwG PERMIT VALIDATION
AOOREss 'a,/,00 I-. gAy$HEORVb . SPECIAL CIRCUIT 5.00
AHO ALrO GA• { 03 EMP.METER OR POLE INS. 15.00 /1
APPLICANTS I F MOTORS SEE FEE SCH.
ADORES
O(OsOC NOS Gt, S e C,A, 1p 22 SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION U.�(�
U I hereby affirm (hat I am licensed under provisions of Chapter') ISSUANCE DATE
Na"' (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F N i Professions Code,and m licen a is in full force and effect. _ ❑ ❑ ❑
z o 6 - License Class - I ic.Number }J4-Q'Z!�._
a Y Date ,t/'- Contractor.- I-�'•�---
IFniA NICA L BUILDING PERMIT
(c w u OWNER-BUILDER DELLA A INFORMATION
w a. y I herebyaffirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
' p VALUATION
r u 0 J Law fonhe following reason.(Sec 7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to CnnSOCCL alter,
a a¢ p improve.demolish,or repair any structure,prim to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o, requires the applicant for such permit to file a signed statement that TOTAL pEpi�•E/
a. w$w he is licensed pursuant to the provisions of the Contractor's License A�r
Hi> Law(Chapter 9(commencingwith Section 7000)ofDwision 3 of the ',`
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
$ the basis for the alleged exemption.Any violation of Section 703 LS 1 STORIES TYPE CONSTR.
a ;- by any applicant for a permit subjects the applicant ma civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 '
of mat more than five hundred dollars($500).1'
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE
their sole compensation,will do the work,and the structure is not 2.00 OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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 SO,FT.FLOOR AREA TOTAL ACREAGE
himself re of intended
his own employees,provided that such improve
hiands mself enhroug nhis or employees,ffered for provided
e. ed thathowevsuch
building GAS-EA.SYSTEM•11NC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILOI USE
builder will have the bu�a1M o'proving that he did no(build or an
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND PB Oma,
❑ 1,as owner of the property„um exclusively contracting with ❑ Cl ❑ ❑
licensedcontractors to construct the project ISec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSIeSSO 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 contractor(s)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.20OW8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. .B.&P.C.for[his WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00Acc.DATE ACC.FILE No.
WO RRS'COpht ISN[g�AT ON D EC.ARATION WATER TREATING EQUIP. 4.00
I herelf�dl0rni that Ilse aZerfl(ica ,'onsent to self-insure,
or a cert ila*Iaate of Workers'Compensation Insurance,or a certified 20NING ENG.SITE NO.
copy there (Sec.3800,Lab.C.l.
Policy No. Company�0_YJ+N L C Ld a E
0 ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Certified copy is filed with the city inspection division.
Z Z 37f MISC.- REFER TO ORD. - ❑ ❑ ❑ ❑
O App¢ant V N V N
)"' y PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.uc.
LU > CIiRT119 CCOMPE EAX IOTINS FROM WORKIiRS'
IU _ COMPIiNSAT10N INSURANCE. PLG,CONTR. LIC.N0. PLO.
Q. O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
� Z hundred dollars(S 10()or less.)
U O 1 certify that in the performance of the work for which this per- DTY. 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.
y Date Applicant ALTER OR ADD TO MECH. q,0p BUILDING
>_ N NOTICE TO APPLICANT: If,after making this Certificate of fix- ,
f.. ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK -
ITTvisions 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)MOQF.M.) 3.00
CONSTRUCT ION LENDING ACENCY AIR HANDLING UNIT(OVERIO)000C.EM.) 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(Sec.- HEATING UNIT ITO 100,000 B.T.U.) 4.001MICROFILM
3097,Civ.CJ.
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC
Lend,,,',Add,"
s-Addrs
I certify that 1 have read this application and state that the above I VENTILATION FAN (SINGLE). 3.00 3-
information is correct. I agree to comply with all city and countyPLUMBING .
mdourm,s and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
'hereby authorise representatives 01' this city to enter upon the019 MECHANICAL. /0
above-mentioned property forinspection purpuws.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of,Lie PERMIT ISSUANCE 3.00 3
granting of this permit MECH.CONT. LIC.NO. MECH.
s-IS-B POLyAtR E 1 3 82 9 TDTA /0 TOTAL
Signature of Applicant/Contractor Date HECriANICAL
- OFFICE COPY