16945 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING�y APPLICATION & PERMIT 16945
p"LO/gS BUILDING - ELECTRICAL-PLUMBING-MECHANICAL Ua7 J
OWNER'S PLAN CHECK VALIDATION
"AME TY. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1. 0 �J IZ'�r'QD
CONTRACTORS -
PODRE55 APPLIANCES-RESIDENTIAL 4.0
- '
_ PHONE PANELS 1 D DATE OFAPPLICATION
A CHITECTPLAN CHECK FEE P.C.NO.
/ PANELS (OVER 200 MPI 000 _
LIC.NO. SIGNS TRANS. 3.00
ARCH,OR ENG, PERMIT VALIDATION
9 Aoo I sr , i� wA`s SPECIAL CIRC 7 5.00
APPLICANTS� eee� Gp a(� Vz� EMP.METER PO ' IN 20.00 Zpe g �
DDRESS •� MOTORS SEE FEE SCH.
AooREss SERVICE CHAN -20.00
o¢ _
FOO LICENSED CONTRACTORS U[CLARA'I'ION % PAMW
rU I hereby.al'brm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
a w (cmmnencing with Section 7000)of Division 3 of(lie Business and BLDG. ELECT. PLG. MECH.
F M i Professions Code,and my license is in full force and effect. 10 1:1 El
z m O License Class Lie.Number
Date Contractor
City of Conprfin) BUILDING PERMIT
¢ ¢ w¢ OWNER-BUILDER DECLARATION
D a INFORMATION
X g a s-. I hereby affirm that I am exempt from the Contractor's License MIS .- - REFER'TO ORD
a O¢ Law for the 1'olowin VALUATION $/FT.
F _ J gmusnn:(Sec.7031.5,Businessaad Professions PERMIT ISSUANCE 10.00 D�d
Code:Anycily orcounly which requiresa permit to construct,alter. -
rc2¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC. ,y m
pD LL requires the applicant for such permit to file a signed statement that TOTAL
a W pt y he Is licensed pursuant to the provisions OI the Contractors License PER MIT TO
HiQ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H
the basis for thealleged exemption.Any violation ppct tSection703 LSinalty STORIES TYPE CONSTR.
d3 _ by any applicant for permit dollars tire($500).):
loucivilpbnally ALTER-DRAIN 5.00
of not more than five hundred dNlars(5500).): -
O 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do lire work,and the structure is not
_- - - intendedor offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 /2._�
Code:The Contractor's License Law does not apply to an owner of .J.a
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mems are not intended or offered for sale.Il',however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
I or improvement is sold within one year of completion, . . .00 the owner. GAS-EASYSTEM-OVER 4 (EA) 2OO(Vl
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of Sec.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Other
❑ A,as owner of tire . .
e property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN 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 proiccts with ac ontractonoticensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ 1 to exempt under Sea ,W&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5,00 ACC.DATE ACO.FILE NO.
WORT:F.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
Or a cerliDCUN of Workers'Connpencation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sce.3800,Lid,C.).
Policy No. Company
O �Q/Certi Cled copy is hereby fumished. FIRE SPRINK ENERGY TQ4
Z Z /R Cerli'• copy s Iile3L : n ne airy ia"ectimn division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
F O Applicant'-'e'�" L� V N V N
rn CERTIFICATI:OF IiXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > CO�(this section Bed 11mN beTdOINpINSJ it RANCE tire permit is for one PLC.CONTR. LIC.N0, TOTAL Y[:] NE] V[:] NE]
0 Z hundred dollars IS 100)or less)
U O 1 certify that in um Performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL h mil is issued, I shall not employ any person in any memcr vo as to ,
O W become subject to the Workers'Compensation Laws of California. Cy ''E
1 Dote Applicant ALTER OR ADD TO MECH. 5.00 BUILDING J ( SBC
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
2 emption,you should become subject to the Workerx Compenanl ion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwilh comply with FEE
C.1 such provisions or this permit shall be deemed revoked. - AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT[OVER I0,000OF.M.) 6.00 SEISMICFEE Z
I 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. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 have read this application and Hale that the above VENTILATION FAN (SINGLE) 4.00
ordinances n correct, I agree to comply with'all city and county PLUMBING
ordinances and state lows relating to building construction, and BOILER-COMP(3 H.P.Or 100,000,B.T.U.) 6.00
hereby entioed representatives inspection
this city es curer upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCM. MECHANICAL
above-mentioned property foripsp of
this
purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,Ioil costs and expenses which CONST.TAX
may in an way accrue against sai it in consequence of the PERMIT ISSUANCE 10.00 O
ranlin G s p get MECH.CONT. UC.N0. MECH.
-3-4 . TOTAL TOTALn
Signature of Applicant/Contractor Date
OFFICE COPY
In
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,. { , �~ �//dAY�•�F,% .//a x "1�•. ' •"•�iig q� . _ ./irk�� _ r/ff'A? �C % "�� fVl
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No. 843
Trdif tratt of
'y Titg of Tupprttno - �1
y� This certificate issued pursuant to the requirements of Section 307 of the _�1
\ ,, .•, r Uniform Building Code certifying.that at the time of issuance this structure was
FT in compliance with the various ordinances of the city regulating building
' r construction or use. For the following: 't .
/ Use Classification RETAIL STORE Bldg. PermitNo. # 16945
qy
c' Group B-2 - 7ype Construction V—N - Use Zone Planned Development % '
Owner of Building Bottaaas/Steven Carlson Address 20735 Stevens Creek Blvd.
J • 4,
/ rr
Building Address
20735 Stevens Creek BlvdCa '
g Locality fnnar}inn lifnrn '
By: •-tnP An{-nntfr•r•i
Date: _ -Ja nnary 'il 1991
\t. Building Official
POST IN A CONSPICUOUS PLACE
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