2295 I ,
XIPPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY � '
BUILDING PROJECT IDENTIFICATION P M��RL,
ADDR9 5
9DILDiNG APPLICATION & PERMIT
ESS
20400 Marian Ave. CU ertino BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
CONTRACTOR
va DN 446-9966
NAME cTORs OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
S 8t M Sprinkler Corp. Lm.NO 261708 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR PPLIANCES-RESIDENTIAL 4,00
f s�th Ave.,Redwood,Qty.368-3393 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
" LIC.No. SIGNS TRANS. 3.00
ARCH.oR ENG. SPECIAL CIRCUIT 5-00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 /�
w O o LICENSED CONTRACTORS DECLARATION NO
u u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
G a (Co PPR,Fci R,with Section 7000)of Division 3 of the Busill.1 and BLDG. ELECT. PLG. MECH.
E. m ° Professions Cod license is in lull f 11 let.
o O iro Licenu CIasB �Lica Numb � rink ie
2 w Dat._-- Contr.do� P
Ix Q w a OWNER-BUILDER DECLARATION S BUILDING PERMIT
o A MISC.- ,• REFER TO ORD INFORMATION
F.
3 LL I hereby affirm shut 1 am exempt from the Contractor's License
u o j Law for the following reason.(See.7031.5,Businessman Professions PERMIT ISSUANCE VALUATION S/FT.
Code:Any city or county which requires a permit to construct,alter, 6.00 1.6
.rM
le ¢ Q O improve,demolish,or repair any*t acture,prior to its i...once,also ELEC.CONTE. LIC,NO, ELEC. Or r V
ab
O 4 requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
wm he is licensed pursuant to the provisions ol'the Contractor%Liccnsc
zi
Law(Chapter 9(commeneing with Section 7000)o1Division 3ol'the
- a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
r o the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTIT
nam 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(S500)J:
❑ 1,is owner III the property,or my eno,loyer,with wages as BACK F LOW PROTECT. DEVICE 2,00 OCC.GROUP RES.UNITS
their sols;can.ensalion,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 tlefoon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himselfre throughhis own emred fors provided ev suchinlprove-
meldsarenot inte..I ,is or employ.... ..If.how.....Om building GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or'mprovement is sold within line year ul'completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that lie did not build or im-
prove lor purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Onan
❑ I,as owner of the Property,um 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:The Contractor's License Law does not apply
to on owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracthe Contracts' License
wirha mntracnhr(s)IicenseA pursuant to SEWER-SANITARY-STORM EA.200fO8.00 TRACT NO. PARCEL NO.
the Contractor's[or such
License Lu w.
❑ 1:am exempt order See. ,B.&P.C.lin IN, WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 Aee.DATE ACC.FILE NO.
WORK ERS'COMITNSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1,have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or u eP,Rticne of Wovkerv'Conlpemati on In I I ,{r •rtified
copy thcr l f$ec.L Co Lab.CJ,- _ A SC_•
Policy No-.'LS761 Compuny_L->>H'N+�"" OY°
Q V Ccmfile o Is here by furnish cd. FIRE SPRINK ENERGY T 24
Z Z ❑ Certifie co rs I- •101 tl car y inspection Jiv"I In MISC.- REFER TO ORD.
O Applicant _ V ❑ N❑ V ❑ N❑
Hy PERMIT ISSUANCE 6.00 Ft000 ZONE A.L.U.C.
CIE �IPIC\"li XEMPI'f) - M WORKERS'
11J _ COM PNSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ v ❑ N❑
IL O (This wcriun need not he completed if the Permit is fur one TOTAL
7) Z hundred doll...IS 100)or Ilea.)
U O 1 certify that in the pcH..mance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issm J,1 shall not em,10Y any person in any mxnncr no an to
U became subject to the Workers'Con.penial ion Laws of California.
O Lu Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING I�O
} w NOTICE TO APPLICANT': If,after..raking this C,NifieWo of
Ex-option.you should become s.bjen to Rule Workers'Compensation APPLIANCE 4.00 PLAN CHECK O
provisions of the Labor Code, you must forthwith comply with FEE p?.
U sural provisions or this permit shall he deenhcd revoked. AIR HANDLING UNIT(TO 10,000QF.M.) 3,00
CONSI'RUCI']ON LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby allium that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance at the work for which this pennir is I...led(Sec MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Address
H EATI N G U N IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this mpplkmtlon and slam that me above VENTILATION FAN (SINGLE) 3.00
ordinances n correct. I agree to comply with all miry and a.uhty BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and stare laws relating to building wily Ju:o0. and
hereby au lomi a representatives of this city to enter uprn the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned Property for in,,,enon purposes.
(We) agree to save. indemnify and keep hmmless the City OI MISC.- REFER TO ORD.
Cupertino gain liabiliric , ,.dgnmR tsN and expenses which CONST.TAX
may in any metro gainst r yin o?Sc of the PERMIT ISSUANCE 3.00
granting oft s emit ® / � /Oy((r) MECH.CONT. LIC.NO. MECH. TOTAL /�
(J�Lj,{/ V TOTAL y 1
Signature f Applicant/Coblunior Dale rl J
OFFICE COPY