C 9139 4APPLICANT.TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION Sf PERMIT '
auarlNG � - n /(�
ADDREss 19925 Stevens .Creek Blvd' BUILDING—ELECTRICAL—PLUMBING—MECHANICAL !`/ 91, 39 .
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ' ".ELECTRIC PERMIT' . FEE
ronos TechnolOPYONE
CONTRACTOR'5
NAME _ UTLETS-SWITCHES-RECEP 10.00/1.00
G. ,5ABAH GO • LIC NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS OR's - APPLIANCES-RESIDENTIAL- 4.00 J ,
1/1 aooREss 669$;OlJPN3 DR•
PLEA A ON CA PHONE 463•x431 PANELS 10.00 DATE OF APPLICATION
agcHlrecr' PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER , 6C.NO. SIGNS TRANS. - 3.00 PAID
ARCH.OR ENG. PERMIT VALIDATION
ADDREss SPECIALCIRCUIT 5.00
zlv TEMP.METER OR POLE INS; 20.00
APPUESANTS
S
ADDRESS - MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00Ify 0' Qf ,
.woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30,00
a U v 1 hereby affirm that 1 am licensed under provisions of Chaptcr9 ISSUANCE.oATE
yaw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w Z Professions Cade,and my license is in full force and effect ❑ ❑ ❑ ❑
z O w — License Class_e (nL_Lie.Number
O w I- w Darc.�rZy.�85 'Contractor—
Elect ,
ontractor—
E le f J
¢ 0w �, OWNIiR BUILDER DIiCLARATION BUILDING PERMIT
w ;LL h I hereby affirm thatng le am exempt from the Contractor's License
MISC.— ` REFER TO ORD INFORMATION
w O¢ Law for the following reason.(Sec.7071.5,Business and Professions VALUATION $/FT.
— J PERMIT ISSUANCE 10.00
P „>g Code:Anycolish ourcounty which reqstructurees a,
prior toconsoarce,also
7 400
¢ ¢ ¢ O improve,demolish,nr anal any slit lure,prior to its iateme t also ELEC.GDNTR. - LIC.NO. ELEC.' x
y w a LL req uire5 the applicant for Such permit In file a signed statement[hal - TOTAL PERMIT TO
he is licensed pursuant to the provisions at the Contractor's License
HiQ Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the •4" - Halon $}rStelR�- -
4 o Business and Professions Cartel or that he is exempt therefrom and QTY. PLUMBING_PERMIT FEE
¢ H $ the basis for the alleged exemption.is the pplicn of Section malty m STORIES• TYPE CONSTR.
i ; � by any man
fora permit dollars tile applicant luacivil penalty ALTER-DRAIN -WATER IEA.) 5.00 '
of not more than five hundred property.
o (my em): ,
❑ Las owner at the property,or my employees with wages as BACK F LOW PROTECT. DEVICE - 4.00 OCC.GROUP RES.UNITS
their sole compensation,will(S the work,and the structure is not
intended or offered for sale (Sec, 7044, Business and Professions DRAINS-FLOORROOFAREACOND. 5.00 "
CoUe:The Contractor's License Law does mit apply m an owner of , , , '
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 so.FT FLOOR AREA TOTAL ACREAGE'
®
himself or through his own employers,provided that such improve.
mems are dot through his orofferedemployees,
or provided thvt s,thebmlding GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owe
builder will have the burden of proving that he did not build or int'
GAS-EA.-SYSTEM-OVER 4 (EA.) 2,00 BUILDING USE
prove for purpose of sale.). - INDUSTRIAL WASTE INTER3000 'RES IND CON PB • Dune,
❑ I,as owner of the property,am exclusively contracting with' . .
- �' O El , Q 0
licensed,contractors In c..street the project(See.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. .6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does nor 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 contractots)licensed pursi,anUtr - SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,B.&P.C.for this WATER HEATER WIVENT' - 6.00 '
reason ,
Owner - Dale WATER SYSTEM 5.00 . nee DATE ACO,FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 . . -
I hereby affirm that I have a certificate of consent to self-insure
ora certificate of-Workers'Compensation Insurance,or.a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Cab.C.1. ,-I -
O Policy Noilt7J_J_Lompuny—EAEe4�A?IN9EASN x_
Certified copy is hereby furnished. FIRE SPRINK. ENERGY T-24
_Z Z 0 Certified copy Is fled with the city inspemion division. MISC.- REFER TO ORD. ❑ [3 -�
Q Applicant V N V N
~ rn ; PERMIT ISSUANCE 10.00
Cr — CERTIFICATE OF:EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
. d0 COMPENSATION'INSURANCE PLG.CONTR. LIC.NO. PLG, -
Z (This section need not he'completed It the pernmit.is far one TOTAL V -N� Y No
hundred dollar.,(S100)or less.) - _
.0 O I certify that in the performance of the work for which this per. OTV. MECHANICAL PERMIT FEE FEE SUMMARY
ILL 1- mit is issued,I shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Laws of California.
i Date Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING,' 68.S0 ,
} N NOTICE TO APPLICANT: If,after'makiny this Certificate of fix-
-F ? enmption,you should become subject to the Workers'Compensation APPLIANCE 5,00 PLAN CHECK
provisions of the labor Code, you must forthwith comply with _ FEE- IfQ.S3
U such provisions or this permit shall be deemed revoked. - AIR HANDLING UNIT(TO 10,000QF.M.) 4.00
CONSTRUCTION LENDING AGENCY`" AIR HANDLING UNIT(OVER IO,O)OC.RM.) 6.00 SEISMIC FEE •56
I herrby'afOrm 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. MICROFILM
3097,Civ.C.). - - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER t 00,000 B.T.U.0.50
LLm rr's`Address ELECTRIC
I rerlify.11wt I have read this application and state fhal tire above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and'date*laws relaling'ro•building construction, and -
hereby.authorize representatives of this,city to enter upon-tire BOILER-COMPIOve,100,000 BTUI SEE FEE$CH. MECHANICAL
above mentioned property for inspection pugmsu.
(We) agree to save, indemnify and keep harmless the City o6 ' MISC.- REFER TO ORD. — -
Cupertino against liabilities;judgments, costs end expenses which PERMIT ISSUANCE -10.00 CONST.TAX
may in'any way accrue against said City in consequence of the
granting of this permit MECH.CONT. LIC.NO. MECH. -
.� :�, TorAL113.,59
slgrl are of Apph`"ant/conlmetnr— �nat37 � , • , - TOTAL' '
OFFICE COPY -