13473APRt.ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
13473
BUILDING
4Df4 OS )q I V
7
OWNER'S
NAME
9 1'Nr1_PHONE 3'sib 7
/hIcF}J}y� MU
ITV ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTORS
UTLETS-SWITCHES -RECEP 10.00/1.0 Q
LIGHTING FIXTURES 10.00/1.00
LIC. NO,
CONTRACTOR'S
CO
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
PHONE
DATE OF APPLICATION
ARCHITECT OR
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
ENGINEER
'Lic. NO.
SIGNS TRANS. 3.00
moo ESS euc.
SPECIALCIRCUIT 5,00 -
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
/'1
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
sie SERVICE CHAN 20.00
-��pLrJ
�/.j/' �Qf 7
�/UAN
LICENSED CONTRACTORS DECLARATION
l
-
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license ism full force and effect.
License Class Lie. Number
Date Contractor
CE DATE
' Q
BLDG. ELECT.
❑
PLG, MECH.
❑ ❑
p',ixl Q
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for ilia following reason. (Sea 7031.5, Businessun l [Professions
Code: Any city or cooky which requires o permit to construct, alter,
V �)
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00 Q �•
VALUATION
$/FT.
EIEC. CONTR. LIC. NO.
ELEC,
TOTAL Ca2lil-
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
PERMIT TO
7
CITY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any vwetion of Section 7031.5
by any applicant for a permit subjects the applicant too civil penalty
of not more than five hundred dollars (S500)J:
ALTER -DRAIN -WATER IEA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve-
mentsxra not intended or offered for sole. If, however, the building
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTALACREAGE
'
GAS - EA. SYSTEM -1INC. 4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose ofsale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.1 2.00
BUILDING USE
RES IND CON PB Oram
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER3000
. .
licensed contractors to construct the prgiect (Sec 7044, Business
and Professions Code: The Contractor's License Law Roes not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
-
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contractors) licensed pursuant to
the Contractor i License Law.
SEWER -SAN ITARV-STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec. ,tl,&P.C. fur this
reason
WATER HEATER W/VENT 6.00
Owner Data �L
WATER SYSTEM 5.00
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure,
or a cenificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy Thereof(Sec. 3800, Lrb.CJ.
Policy No. Company
FIRE SPRINK
yN
[-]v
❑
ENERGY T-24
N
❑ ❑
O Certified copy is hereby furnished
A 0licCertified copy is filed with the city inspection division.
MISC. - REFER TO ORD.
C17RTIFICATI: Op EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.O.C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
PLG. CONTH. LIC. NO.
PLG.
TOTAL
V ❑ N ❑
Y ❑ N ❑
hundred dollars(S 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any munnerso as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workeri Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
emption, you should become subject to the Workers Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT(OVER 1000C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
EXHAUST. HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued (Sec.
3097, CR.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Leader's Address
HEATING UNIT (OVER 100,000 B.T.U.)9.50
CTR I C
ELECTRIC
s--d`1P
VENTILATION FAN (SINGLE) 4.00
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER H.P. Or 100,000 B.T.U.1 6.00
B01 LER-COMP Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
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
may in any way account,against and City in consequen of the
PERMIT ISSUANCE 10.00
CONST. TAX
grantipg0 his i
MECH. CONT. LIC. NO. MECH.
O
4
- TOTAL
TOTAL
ignalurc of Applicant/Contractor ate
'
OFFICE COPY
•
Input Permit Numtiar i-.�
PERMIT#:
R63W
ARCHITECT:
VALUATION:
6432
APN:
35906039
LICENSE #:
ISSDATE:
1/26
SITUS STREET:
ROSE BLOSSOM
SUBDATE: 1/26/99
SITUS NOG:
949T-PLCHKDONE:
AVE,CT.ST.RD:
DR
TYPE: RSR
LATE CODE:
N,S,E,W:
DESCRIPTION: REROOF
BLDGDEPT:
NOG:
ENGDEPT:
CITY:
N
PLANDEPT:
ZIP.
95014
PUCHKIIEQCATEGORY:
CMA:
C:
CATEGORY
LTRFlRE:
LOT#
DATEDUE:
SANDIST:
ID:
Commmaial
HLTHDEPT:
OWNER:
OWNER
KRONER 7HOMASHET AL
949 ROSE BLOSSOM DR
CAsq#STRCTENG:
CE-sgGllG:
TOTAL:
ADDRESS:
LN,sgGIIG:
INSPHOLD:
'Y.STREET2IP:
CUPERTINO C4 95
PHONE:
Residanlial
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CONTRACTOR:
REROOFlNG
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LIC#:
IMES
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