5866 �+2PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT
ADDRESS ODRESSDREss 10400 Ridgeview Court
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL ' 5866
NAMERa a* yti hti,'s"S'f.�yp,k., - i7 - , PLAN CHECK VALIDATION
OTV kELEC,TRIQ.PERMITshx"t, !"y* F•„EE ,.
6g2o VEfiVO� PHONE •4•, ^': k
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
Viking Fire PrLgetSct lOn LIGHTING FIXTURES 5.00/1.00
-
CONTRACTOR'S
ADDRESS - APPLIANCES-RESIDENTIAL 4.00
E55
969 Industrial,HUad,' Ste• I PANELS 5.00 DATE OF APPLICATION
ADRRCHICT TE )•' • SIGNS 6.00 'PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNSTRANS. - 3.00
ARCH.ORENG. SPECIAL CIRCUIT - 5.00 PERMIT VALI DATION
ADDRESS V.C• Wong & Associates, Inc.
2901 ,Gordon Santa Clara z8 A. TEMP.METER OR POLE INS. 15.00
Arvr'.
ADDRESS
95051 MOTORS SEE FEE SCH. J
SERVICE CHANGE 10.00
wO O .LICENSED CON'T'RACTORS DECLARATIONIt
u I hereby affirm that Iam licensed under provisions of Chapter 9 ISSUANCE DATE
N z w (commencing with Section 7000)of Division 3 of the Business and
y g BLDG. ELECT. PLG. MECH.
r N z Professions Codµarylany license is in full forced rL b-
z o M 0 License Class Lie.Number_l. - E
3 w w Date Contractor
r
i:: x s , -VIk7. BUILDING PERMIT
M X < OWNER-BUILDER DECLARATION - , -
o n u NFORMATION
E:
g LL I hereby at firm'that I am exempt from the Contractor's License MISC.- REFER TO ORD
Hu0¢ Law fur the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 Vf}UAATIIIOONN SIFT.
Code:Any city or'counlywhich requiresa permit to construct,alter,
ac
2< N improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. TELE
n .
wDLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO.
m he is licensed pursuant to the provisions of the Contractor's License
�za Law.(Chapter 9(commencing with Section 7000)of Division 3 of the 'it kA_I 1 .., x ,{.tlslL[.I. Install fire sprinkler
4 e Business and Professions Code)or That he is exempt therefrom and QTY.,d;j,.: PLUMBING PERMIT FEE-.
IC r C, the basis for the alleged exemption.Any violation of Section 7031 5 s, .'¢'x STORIES TYPE CONSTR.n 3.- by any applicant for a permit subjects the applicant toa civil penalty
ofnot more than five hundred doll..(5500).): ALTER-DRAIN&VENT-WATER (EA.) 4.00
O I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 occ.eflouP RES.UNITS
their sole compensation.will do the work,and the structure is not s
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
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve
,, meals are not intended proffered for sale.If,however,the budding GAS-EA.SYSTEM-111NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im
prove for purpose of rale.). RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 20.00 ❑' ❑ ❑ ❑ ❑-
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 AWESSORSPARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to no owner of property who builds or improves thereon,unit who LAWN SPRINKLERS-OVER 5(EA.) 1,00 '
contracts for such projects with a contexclor(s)licensed pursuant to -
theContractor'sLicenseLaw. SEWER-SANITARY-STORM 'EA.200ft/8:00 ' TRACT NO, PARCEL NO.
I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 4.00
mason
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 -
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.). -
Policy No. 'Company -
0 X Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division.
MISC.- REFER TO ORD.
I" O ,, Applicant V ❑ NE] V C] N❑
CC CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTH. LIQ NO. PLG.
CL O IT his section need not be completed if Zhu permit is for one • TOTAL Y❑ NE] V ❑ N❑
:DZ hundred dollars fS 100)or less.) '^y
L) O 1 certify that in the performance of the work for which this per `OTVR '�"5 - ' x;IFEE`SIJMMARY
LL I- mil is Issued,I shall not employ any parson in any manner so as to a:Kgg; n > i"i•s;ii`.MECHANICAC7PERMIT IFEE:,
U become subject to the Workent Compensation Laws of California
a
Date-Applicant ALTER OR ADD TO MECH. q,q0 BUILDING 383.00
} W NOTICE TO APPLICANT': If,after making this Certificate of hx
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00 FEE 248.95
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE 5.81
- 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.).- - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T,U.)7.50
Lenders Address ELECTRIC
1 certify that l have read this application and State that the above VENTILATION FAN (SINGLE) 3.00
nd
information is correct. 1 agree to comply with.II city acounty PLUMBING
'. ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives or this city to enter upon the BOILER-COMP over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection 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 3.00 CONST.TAX
may in any way accme againsrsaid City in consequence of the
grantingof this permit. MECH.CONT. LIC.NO. MECH.
8-22-84 TOT"` 'TOTAL
$ignalum of m
APPlicl/Conlm637.76
cipr Dale � -
OFFICE COPY -