14205 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
. BUILDING PROJECT IDENTIFICATION 1 PERMIT NUMBER
BUILDING APPLICATION & PERMIT 14205
,�iy o Rr.inbow Dr. , Lot $4 BUILDING - ELECTRICAL-PLUMBING.-MECHANICAL
>t OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
agPHONE -
NONrRAcroR
NAME s OUTLETS-SWITCHES-RECEP 10.00/1.00
Central Service CO. LIC.NO. 171537 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR oR's PPLIANCES-RESIDENTIAL 4.00
CONTRA
b25 rharles S PHONE _ PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
oR PANELS (OVER 200 AMP) 20.00
ENGINEER
Lie.NO. ISIGNS TRANS. 3.00
coo'Ess ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS - SEE FEE SCH. C�,
ADDRESS SERVICECHANGE 20.00 '--v-'+_ci--rsr-�
625 Charles St.
w O o LICENSED CONTRACTORS DECLARATION /
a u w I hereby affirm that I am licensed under provisions of Chapter 9 ISSU( DAT
H Q u (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
�fe Professions Code n�dJ,,rrpp.yy license is in full force,'Ir�jyf ct. ❑ ❑ ❑ ❑
z o Licensep��lassll��y .]D_Lic.Numhcr_.L/.1 3.7 ,
0 y F w Dale-,L, l=8.7 Contract-Central-Servi le
¢ se s BUILDING PERMIT
¢ ¢w OWNIi R-BUILUIiR UECLA RATION INFORMATION
wo a MISC:- REFER TO ORD
; u w I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
Huoa Law for the following reason. Sec.7031.5,Businessandl'rofesocals PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
¢ improve,demolish,or repair any stnmtufc,-prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
B,
requires the applicant for such permit to file a signed statement that TOTAL ERMIT TO
6 W m he IS licensed pursuant to the provisions of the Contractor's'License
Law(Chapter 9(commencing Willi Section 700()of Uivieion3ofthe
¢ Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
¢ r$ the basis for the alleged exemption.Any violation of Section 7031.5 - STORIEST P CONSTR.
A. applicant by any applicant for a permit subjects the applicano.civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).h
❑ I,as owner of the property,or my employees will,wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and ProfessionsDRAINS.FLOOR,ROOF,AR EA,COND. 5,00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work 17 FIXTURES-PER TRAP 5.00 --- SO.FT,FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve- GAS-EA,SVSTEM-I 6.00
ments are not intended or offered for sale.If;however,the building
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 huild or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 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.8. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who ILAWN SPRINKLERS-OVER 5(EA.) 1.00 -
contracts forsuch projects witha contractors)licensed Pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contracloi s License Law. TRACT N0. PARCEL NO.
❑ lam exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00 ---
mason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPIiNSATIOND17CLARAI'ION WATER TREATING EQUIP, 500
I hereby affirm that I have a certificate ofconsent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy tbµslS3i0o,Lab.c.)'Pacific Co
Policy N�ll.� Company _Q_
0 ❑ Certified copy is creby umished, FIRE SPRINK ENERGY T-24
Z Z a cc UP o s wish the t ',eclion division.
O APVlicnntc _ _ v MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
Fy PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
fY CERT'I IrICATIi OP IiXIiMPT'ION I' OM WORK Ii RS' ---
LU > COMI'IMATION INSURANCE �p 5R. LIC.N0 pLG,
CLO (This section need not he completed it Ihe'pennit is fur ane L�1 `Service 171537 TOTAL --- Y❑ N❑ Y ❑ ,N❑
Z hundred dollars($100)or IC,.,I
U O 1 certify that in the perfornmnce of the work for which this per. QTY. i MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,I shall not employ any person in any mannerso as to
O W become subject to the Workers'Compensation Lows 01 Cali1'nntla. BUILDING
a,
Date-Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT': 11',al'ler making this Certificate of Fs-
? 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
C,.3 such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 -
the 3097cQv C ance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
t ,. Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with 311 city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
1 hereby authorise representatives of this city to enter upon the
above-mentioned Property for inspection Purposes. BOILER-COMP lover 100,000 BTUI SBE FEE SCH. MECHANICAL
- .
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
0 Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
ftmay in any way accrue,against said City in consequence of the PERMIT ISSUANCE 10.00
guff penI. - MECHCONT. LIC.NO. MECH.
-13-87 TOTAL TOTAL
ature ofApplicant/ContraW Data
OFFICE COPY