0566 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN 03-10304
V E MITNUMEER
BU I LDING PROJECT I DENTIFICATION gppLICATION & PERMIT 0566
20400Mariani Avenue
ED ILDING
' ADDRESS
. BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S (415) PLAN CHECK VALIDATION
-_\ NAME CITY. ELECTRIC PERMIT FEE
S -va Company PHDNE493-2200
coNAME NTRAcrDRs UTLETS-SWITCHES-RECEP 5.00/1.00
Fngineeri IC.NO, 01070 ILIGHTING FIXTURES 5.00/1.00
r,ONrRAcroR S [APPLIANCES-RESIDENTIAL 4.00
ADDRESS p Fanta Clara
3271 Kifer Rd. PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT 2192 SIGN$ 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
' uc.NO. ISIGNS TRANS. 3.00
ARCH.OR ENG. ISPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 �ys/GL
o o LICENSED CONTRACTORS DECLARATION Will o
u w I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w< m (commencing with Section 7000)of Division 3 of the Business and r'I BLDG. ELECT. PLG. MECH.
H y z Professions Code,and my license is in full force and effect. V ❑ ❑ ❑
o m - License Class Lic.Number.
Z
H Date -�-16-Contractor 1rJ 071
a y f 30 A113
BUILDING PERMIT
c ¢ w a
OWNER-BUILDER RBUILDIiR UECLA RATION INFORMATION
o MISC.- REFER TO ORD
w 3 LL H 1 hereby affirm that I am exempt from file Contractor's License VALUATION
H .. o a Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter.
oimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC,NO, ELEC. 42
O LL requires IIIC llpphcanl f0!such pellnll l0 f1IC a signed Sl'JICI11CI11 IIIaI TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
w
H z as Law(Chapter 9(commencing with Section 7000)of Division 3 of the
- a Business and Professions Code)or that he is exempt therefrom andDTV. PLUMBING PERMIT FEE P
i rp gni- nll
rc �o the basis for Oa alleged exemption.Any violation of Section 7031.5 STORIES TYPE D R.
au Ate _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4,00
1
of not more than five hundred dollars IS500).):
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure a 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 mol 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 TOTAL ACREAGE
himself or through his own employees,provided that such improve-
centsare not intended or offered for sale.If,however,the huilding GAS-EA.SYSTEM-I INC.4 OUTLETS 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 int- RES IND CON PB Oce,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec 7044.Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'Tile Contractor's License Law docs not apply
to an owner of property who builds or improves thereon.and who LAWN SPR INKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractions)licensed Pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ I:on exemptundcr Sea .If Sp C.tin mix WATER HEATER W/VENT 4.00
reason
Dale Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby uffirn that I have a certificate of consent to self-insures ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800.Lab.C.).
Policy No. Company_ 1'1[1 T1TL�
Q ❑ Cerlifed copy is hereby furn�tq$1,(f H qq-(1 FIRESPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with th2'2i1schtJdt4ixioN. MISC.- REFER TO ORD.
APP1lcaml v ❑ N❑ v ❑ N❑
F' 0 PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.c.
CC CERTIFICA'IF OF EXEMPTION FROM WORKERS'
LU 1 COMPFNSWION INSURANCE PLG.CONTR. LIC.NO. PLG, v E] N❑ Y C:] N CD 0 (This section need not be completed if the IF..ndL
t is for one TOTA
Z) Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL mit is issued,1 shall not employ any person in any nenner so as to
U become subject to the Worker2Compensolion Lawsof California. BUILDING
LU Dale Applicant ALTER OR ADD TO MECH. 4.00 25 .00
a
} rn
NOTICE prion,TO should become
If,after making this rv'Certificate of Ex-
Z em vision you Shaul.)become subject m the W'orke it Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must drevoke comply wish FEE 16. 25
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 5.00 SEISMIC FEE 50
1 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 MICROFILM
3097,Civ.C.). None UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
N information is correct. I agree to comply with all city and county BOILER-COMP13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
( ordinances and state laws relating to building construction, and
I.CMby amhorire representative of this city to enter upon the BOILER-COMP (OYer 100,000BTUISEE FEESCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to wve, indmnnii o if- hunnluss theCity of MISC.- REFER TO ORD.
Cupertino against liabilities,judg ti, costs and expenses which CONST.TAX
may i any way accrue against d City in consequence of the PERMIT ISSUANCE 3.00
I, t oflhu Cost. G MECH.CONT. LIC.NO./22/$ TOTAL TOTAL 41 .75
>fgTatmj_ AjpIicm!86,;=tm77Dotc
OFFICE COPY