14206 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT
A14206
ADDRESS
212 50 RE,inbow Dr. , Lot #7 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
217.
OWNERS PLAN CHECK VALIDATION
NAME QTY. - ELECTRIC PERMIT FEE
The Gregory Group PHGNE595-2100
CONTRACTORS,. UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
Central Service CO.LIa.N1,171537 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR S
AOb 7 APPLIANCES-RESIDENTIAL 4.00
Charles Street N,GN�98-0556 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP). 20.00 PLAN CHECK FEE P.C.N0.
OP
ENGINEER '
Lie,No. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT$ MOTORS SEE FEE SCH. n
ADDRESS
625 Charles St., SJ 95112 SERVICE CHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARATION
¢v v I hereby at no that I um licensed under provisions of Chapter 9 ISSUANCE DA E
u a N (commencing with Section 7000)of Division 3 orft�the{eB�u{siness and BLDG. ELECT. PLG MECH.
H h i Professions Cot-36 sly license is in full force 1/IM7 ❑ ❑ ❑
o i m o Licen las Lic.Number 7.]
F ,A F a Date
_B�] Controct�ntrtll-.SQ]'-,VIE
a x E
¢ ¢ a OWNER-BUILDER DECLARATION BUILDING PERMIT
o ii u INFORMATION
X ; LL n I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
Fay J Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter,
2 ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
E a LL requires the applicant for such permit to file a signed statement that TOTAL
a $w he is licensed pursuant to the provisions of the Contractor's License- MIT TO
FZ) Law(Chapter 9(commencingwith Section 7000)ofDivision 3 ofthe
a Business and Professions Code)or that he is exempt therefrom andETV. PLUMBING PERMIT" FEE
¢=$ the basis for the alleged exemption.Any violation of Section 7031.5 STO IE TYPE CONSTR.
a3 � by any applicant for a permit subjects the applicant to a civil penally 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 FLOW PROTECTDEVICE 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 Professions DRAINS-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 -__ 50,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.l f,however,the budding GAS-EA.SYSTEM-I1NC.4OUTLETS 6.00 .
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 AES IND CON PB Omar
O 1„as owner of the property,am CxClusivcly contracting with
licensed contractors to construct the project(Sec. 7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS 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 for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ftI10.00
the Contractor's License Law. TRACT NO, PARCEL NO.
eas❑n I an exempt under Sec. ,B.&P.C.for this 1 WATER HEATER W/VENT 6.00 _
I0
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy tll,tµtsfl GI�380Q Lab.C.
Policy Company dC_.1f1C-CORK-
0 O Certi is c py is I,reby furnish ed. FIRE SPRINK ENERGY T 24
Z Z }'{1 Certif1 o with the Ci 'sspection division. MISC- REFER TO ORD.
O Applicant Y ❑ NE] Y ❑ NE
Fin PERMIT ISSUANCE 10.00--_ FLOOD ZONE A.L.U.C.
LU CERTI PICCOM E EXEMPTION OM WORKERS'
W � COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG, �
CL ❑
This secretin need not he completed if the permit is for one Central Service TOTAL --- Y[] NE] Y [:] No
Z) Z hundred dollars 151001 or less.)
L) O 1 certify that in the performance of the work for which this per. GTY1 MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued, I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
n
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex
F ? emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the LaborCde, you meal forthwilh comply with FEE
U such provisions or this pandit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C-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 I'or EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT ITB 100,000 B.T.U.) 8.00 MICROFILM
3097,Cie.C.).
Lender's Name H EATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and stats:that the above 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.OF 100,000 B.T.U.) 6.00
hereby authorize representatives falives of this city to enter upon the BE ER IOvor 100,000 BTU)SEE FEE SCH. MECHANICAL
hereabovby authorize
ned property tarvespef the purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which' - PERMIT ISSUANCE 10.00 CONST.TAX
may in any wgy accrue against said City in consequence of the
granof thi pe T. MECH.CONT. LIB.N0. MECH.
11-13- 7 TOTAL TOTAL
Signature of Applicant)Contr r
- OFFICE COPY