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09578 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY " T BUILDING PROJECIDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT ' On 7 ADDRESS ' ' `�' I 7C) Orange Blossom- BUILDING-- ELECTRICAL-PLUMBING-MECHANICAL OWNERS - - PLAN CHECK VALIDATION NAME OTV. ELECTRIC PERMIT - FEE - � Mr. Rex Glildby PHONL984-0360 • CDNAME /1,.rRACTos UTLETS-SWITCHES-RECEP 10.0000 Atlas Hetting UC.No.46 266. LIGHTING FIXTURES 10.00/1.00 ADoRs ADDRESS APPLIANCES-RESIDENTIAL 4.00 ADDRESS 1 Commercial Ste PHDNE O 16 PANELS 10.00 DATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO. O OR ENGINEER s , ' ruc.NO ISIGNS TRANS. 3.00 ARCH.OR ENG. ISPECIAL CIRCUIT 5.00 PERMIT VALIDATION ADDRESS ZIP EMP.METER OR POLE INS. 20.00 APPLICANT'S ' �J .' ADDRESS MOTORS SEE FEE SCH. /V x' SERVICE CHANGE 20.00 ' , / o o LICENSED CON'T 'RACTORS DECLARATION TEMP.POLE 30.00 �/ �l � - u I hereby affirm that I dam licensed under provisions of Chapter 9 ISSUANCE GATE a a n (commencing with Section 7000)of Division 3 of the Ilusiness and BLDG. ELECT. PLG. MECH. H F i Professions Code,�A 2iii, V(cense is in full for4p o M License CLie Numb-r ❑ ❑ ❑ ❑ o Z r w Duce�� ConTmctor�tla8-Heat BUILDING PERMIT -4 ¢ ¢ wa OWNER-BUILDER DECLARATION - "INFORMATION '- 1�,} o e_ O MISC.- REFER TO ORD X ; N 1 to,the affirm that I sm exempt 031.5 The Contractor's License '0 o4 Lawforthefollowingreason.(Sec. uires a,ermit tocand Professions PERMIT ISSUANCE 10.00 VALUATION ce - Code:Any city sh,or my which structur a permit o its issuance, ce,her, ¢ Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. - 0¢ requires the applicant for such permit to file a signed statement that TOTAL - PERMIT O . a es LL he is licensed pursuant to the provisions of The Contractors License Le Law(Chapter 9(commencing with Suction 7000)of Division 3 ofthe - < Business on and Professis Code)or That he is exempt therefrom and DTV. PLUMBING PERMIT FEE ¢ t$ the basis for the alleged exemption.Any violation Of Suction 7031.5 STORIES TYPE CONSTR. a ; by any applicant for a permit subjects the applicant to a civil penalty' ALTER-DRAIN -WATER (EA.) 5.00 of not more Than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS their sole compensation,will do the work,and the structure Is not intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONE). 5.00 Code:The Contractor's License Lew docs not apply to an Owner of property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SG.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,fors.provided that such improve- mcuts r�mselfo through riughhis or own efurudfeesale.lf,ed that s(he building GAS-EA.SVSTEM-11NC.40UTLET$ 6.00 40 or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE builder will have the burden of proving that he did not build or int- RES IND CON PB Omer prove for purpose of sale). INDUSTRIAL WASTE INTER. 30.00 Cl 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors to construct The project(See. 7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Code:The COntmClor'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 for such projects with a contractors)licensed pursuant to The Contractor's License Law. SEWER-SAN ITAR V-STORM EA.200ft/10.00 TRACT NO, PARCEL NO. ❑ lam exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00 Ieaoa Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKERS'COMPFNSAT10N DECLARATION WATER TREATING EQUIP, 5.00 I hereby affirm that I Imvt a certificate of consent to self-insure. ZONING or a certificate�foff.,W��orkers'Compensation Insurance,or a certified ENG.SITE NO. if PrcYNO V9' Allied Pacific O ❑ Certified copy is hereby furnished. FIRESPRINK ENERGY T-24 Z Z 70 Ccrtific yfy�y Is d t 05e city inspection division. MISC.- REFER TO ORD. O Applicant�TtlSfl�i@S�g Y❑ N❑ Y ❑ N❑ c N Cl:R1'I FICATI:OF Ii XFSIPTION FROM WORK[SRS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. LU > COMPENSA'T'ION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ NEI 0 (This Section need not he completed if the permit is for one TOTAL ::) Z hundred dollPrs(8100)or less.) U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE -FEE SUMMARY LL.H mil is issued,I shall not employ any person in any manner so as To O U become subject to the Workc,x Compensation Laws of CuliWnna. v . . 0. . Dale Applicant ALTER OR ADD TO MECH. 500 BUILDING } So NOTICE TO APPLICANT: If,after making this Certificate OFF", F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK provisions 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=C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOMC.F.M.) 6.00 SEISMIC FEE hereby ul'I ism That entre is a construction lending agency I'or EXHAUST HOOD(WITH DUCT) 5.00 0Cperl'ormance of the work for which this permit is issued(Sec. HEATING UNIT IT 100,000 B.T.U.) 8.00 MICROFILM 3097,Civ.C.L 1 8 00 Lender's Nene HEATING UNIT(0 VER 100,000 B.T.U.)9.50 ELECTRIC Lender's Address I certify that I have read this application and state that the'ahove VENTILATION FAN-(SINGLE) 4.00 information is correct. I agree to comply with all city and county PLUMBING ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 hereby authorio, representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE F SCH. MECHANICAL above-mentioned properly for inspection purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER ORD. Cupertino against liabilities,judgments. costs and expenses which CONST.TAX may in any way accrue against mid City in consequence of the PERMIT I UANC 10.00 lO�OO gr' g 11 •m Q r MECH L .N . TOTAL �L pp -a�$� Atlas Heating 46$266 18.00 TOTAL 5 arc ofA licam Corrraclor Data OFFICE COPY