6994APPLICANT,TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
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APPLICATION 81 PERMIT
BUILDING =ELECTRICAL- PLUMBING -MECHANICAL
PERM IT NUMBER
-
[� (j (] /�
o J J �i
RLDNG
aooREss
AOD.ESS 20330 Stevens Creek
Blvd.
OwrvERS/-�� .,y.'.�
NAME x..UjJey 1,,,yyy0 City Center
Associates B PHONE 446-0157
q' y'�' •i 4 tt+n� �� ; 'k
QTnv,.'' gs,k'.*,'ELECTRIC P�ERMITa,.;a'p FEE,
PLAN CHECK VALIDATION
CONTRACTORS
NAME
NAME
21'7 UTLETS-SWITCHES -RECEP
T
Pim Electric LIC. LIC. No. 5273
'
f^^
IGHTING FIXTURES d ,��Ia�/1.06' 428
CONTRA C.O.Box 238Toi�2Jp0
ADDRESS
9 ppLIANCES- RESIDENTIAL 4.00 396
_
Q AN ELS /0 600,
Alameda Ca.94501 0NE522-5335
DATE OF APPLICATION
RRC
GR
O
ENGINEER
LIC. No.
SIGNS 6.00 /0 (p Or
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
AnCH, OR ENG.
ADDRESS
ZIP
SPECIAL CIRCUIT. 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
Anon ESS T
ADOHF:SS C-O.BOX 2380
31 OTORS FAEDIFEE SCH.
SERVICE CHANGE 10.00']
Alameda, Cal.94501
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LICIiN S1iI) CONTRACTORS DECLARATIONNOV
I
186 5 HeatingISSUANCE
I hereby affirm that I am licensed under provisions of Clmpter 9
(,e m umeing with Seelion 7000) of Invision 3 0l the Business and
Professions Co gd�ny license is in full force �,C(f�yJ,
Liccnac fjaFsiJA}f� Loc. Number
DATE
I o ape mo 37a-
BLDG. ELECT.
PLG.
MECH,
-
Date_ll/ �-:L7 Cmltmctor
a BUILDI NGIPERMIT -
-t -"-'
INFORMATION
OWNER-BUILDERDIiCLARATION
I hereby affirm that 1 am exempt'frothe Contractor s License
m
Law for the fallowing reason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter,
in prove, demolish, or repair any structure, prior to its issuance, also
r2quires the applicant for SOCK permit to file a signed statement tat
he Is licensed pursuant to the provisions of the Contractor's Liccroc
Law (Chapter 9(commencing with Section 7000)0(Division 3 ofthe
Business and Profesa,ma Code) or that he is exempt therefrom and
MISC- REFER TO ORD q7
.
-
PERMIT ISSUANCE 6.00
VALUATION S/FT.
-
ELEC. CONTR. LIQ N0.
ELEC.
TOTAL • g
PERMIT TO
OTY. PLUMBING.PERMI-T n' FEE
STORIES
TYPE CONSTR.
the basis, for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of nm more than five hundred dollars ($500).)-
ALTER-DRAIN'&VENT-WATER (EA.) 4.00
❑ I, 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 2.00
OCC. GROUP
REB. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professihihs
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees; provided that such improve-
ments are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 4.00
SG. FT. FLOOR AREA
,
TOTAL ACREAGE
GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or 1111.
Prove for purpose of the p
❑ of the properly. atm exclusively ling with
GAS
GAS - EA. SYSTEM -OVER 4 IEA.) 1.00
BUILDING USE
IND CON. PR Other
Q
INDUSTRIAL WASTE INTER. 20.00
d contra t
licensed contractor., od to construct the project (Sec. 7044, Business
. 7044,
and Professions Code: The Contractor's License: Law do not apply
to owner 01 property who builds improves and who
LAWN 'SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts tr used pursuant
the Cont for such cenjeCL with it contractor(s) IICCnSCd pnfSllalll IO
the Law.
SEWER -SANITARY -STORM EA. 200([)8.00
TRACT NO,
PARCEL NO.
lane xe ptunse
❑ lam exempt unJer¢ec.'' "li.&P.C. I'Or tllis
reason
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WORKERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 4.00
1 heteliy affirm that I have a certificate of consent to self -insure,
or a certificate of Workers% Compensation Insurance, or a certilied
ZONING
ENG. SITE NO.
copy ihen�+GASeQ_jBOr§gth.C.l.Royal Ins.
policy No. 44.•bb �•@eilhSplVlty
'❑ Certified copy is hereby furnished.
X Certified copy is filed with the city inspection division.
Applicant
FIRE SPHINK
Y [] N0
ENERGY T 24
Y C] NCJ
., MIC. - EO.
SREFER TORD
CERTIWCATE OF EXF:MPI' ION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
PLG. CONTR. LIC. No.PLG.
TOTAL
Y N�
Y ❑ N
Imndred dollars (8100) or less.)
I certify that in the performance of the work 1'or which this per
not o: issued, I shall not employ any person in any manner so as t s
F' s "• '_a +
OTY. t , ki/ 'r MECHANICAL" PERM t FEE,
µ
iF,EE`SUMMARV
x «-„,.: cexB �E..•"
BUILDING
become subject to the Workers' Compensation Lawsof Califo...is.
[lamApplicant
ALTER OR ADD TO MECH. 4,00
NOI WE TO APPLICANT: If, after making,this Cenificale of Ex-
emption, you should become iubjcct to the Workeri Compenotitm
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
PLAN CHECK
FEE
AIR HANDLING UNIT (OVER 10MC.F.M.) 5.00
SEISMIC FEE
,
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
(]to performance of the work for which this permit is issued (See.
3097;0mC).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
HEATING UNIT (OVER 100,000 B.T.U.P.50
ELECTRIC
Ve�
Lender's Address
i certify that I have read this application and stale that the above
VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county
Ordinances and slate laws relating to building co nstuclion, and
PLUMBING
BOILER-COMP(3 H.P. Or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH:
MECHANICAL
hen,by authorize representatives oI'this city m enter upon the
above-mentioned property for inspe'' n purposes.
MISC. - REFER TO ORD.
CONST. TAX
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(We) agree t0 save, indemni an keep harmless the City of
Cupertino against liabilities, ju mm . costs ant[ expenses which
may, in ny w accru; ga' sl Cilys in consequence of the
gran f Ihls
✓L�..�C W13/85
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO. MECH.
TOTAL
'
TOTAL
Sign re of Applicant/Con ractor
Date
OFFICE COPY