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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
(LDING- ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
5667
annLDnNGfinnanAssoc,
TIMM Stevens Creek Blvd. St. 1
OWNER'S Volkmann & As
Vag
PHONE 52-7466
sT''R q�r;4'L;yy' ;NS? Nr{T-"i•iP'f U3 )YE
QTY:'' rc' 'ELECTRIC'PERMIT a� xJ,
1 tinct
PIAN CHECK VALIDATION
NAME
OUTLETS UTLETS-SWITCHES -RECEP 5.00/1.00
eninsula Air Condo IRGD 436343
DATE OF APPLICATION
LIGHTING FIXTURES 5.00/1.00
CONTRACTOR ny
XXUVLL W PH
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT
OR
ENGINEER
uc. No.
SIGNS 6 OO
PLAN CHECK FEE P,C. NO.
SIGNS TRANS. 3.00
ADDRESS ENG
ZIP
SPECIALCIRCUIT 5.00PERMIT
VALIDATION
J'
QW
EMP. METER OR POLE INS. 15.00
A
DRESS ss
ADoR E
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DCCLARATION
_
I hereby uflom that I un licensed under provisions of Chapter 9
ICommencingith Section 7000) 01 Division 3 .1 the Business and
Prot...ion, C z( my license re is in full to. f
Llcens�I Co Lic. Number,�'IJJ��VL Ys7
_Cr�{x
o'�ontraclor LCSl
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
OWNERBUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License
Law for the following rema
o(Sec. 7031.5, Businessand Professions
Code. Any city or County which requlresa permit tuconslracL ante,,
improve, demolish, or repair any structure, prior to its Issuance, also
requires the applicant for 9Sh permit to IIIe a signed statement Thai
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 0(commencingwith Section 70001nf Division 3 ofthe
and Prolcssiom Code) or that he is exempt therefrom and
the hasis for the alleged exemplion. Any violation of Section 703 L5
. 's ._ BUILDING PERMIT �dy'ry
.. 'seINFORMATION<,.':• '
MISC. - REFER TO ORD
VALUATION
S/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO.
ELEC,
TOTAL
PERMIT O
ccBusiness
_
- - '"
OTY. `^ y PLUMBING PERMIT v'•q":-"�'jFEE^'
- v- '
STORIES
TYPE CONSTR.
by'any applicant lot a permit subjects the applicant to a Civil penalty
not ore than five hundred dollars (5500).):
than
ALTER -DRAIN -WATER (EA.) 4.00
0 1 , asof
of the properly, or my employees with wages as
their sole cum sensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, GOND. 4.00
intended or offered for sale (Sec. 7044. Business and Professions
Code: 'rhe 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 -
men« are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 4.00
SQ FT, FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - I INC. 4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that tie did not build or im-
prove for purpose of sale.)'
❑ 1• as owner of the property, am exclusively contracting with
GAS, EA. SYSTEM - OVER 4 (EA.) 1,00
BUILDING uSE
RES IND CON PB Orner
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20,00
licensed contractors to construct the project (See. 7044. Business
and Protemions Code: The Contractor's License Law does not apply
to in owner of properly who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1 AO
ASSESSORS PARCEL NO.
Contracts fur such projects with a contractors) licensed pursuant to
IIIc Contractors License Law,
SEWER -SANITARY -STORM EA. 200tt/8.00
TRACT NO.
PARCEL NO.
❑ lun(eecmpt under Sec. .B.&P.C. for this
Oason
WATER HEATER W/VENT 4,00
wner Dam
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKERS' COMPIi NSATION DECLARATION
1 hereby affirm that I have a Certificate ofenn.ent to sel Ginsure.
or a ertifieate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
gl' ,"'.af2yi`2V;4",Vremont Ind. Co.
❑ Certified copy is hereby furnished.
t Certified Copy is filed with the city inspection division.
Applicant
FIRE SPRINK
Y ❑ No
ENERGY T 24
Y ❑ No
MISC. - REFER TO ORD.
CFR'rIFR'ATEOF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
section need nor be completed if the permit is for one
v❑ N❑
Y❑ NC](This
DTV. i +} MECHANICAL PERMITii Z"Nik 'tPEEF.
_ _ j"
�:N *'FH@SUMMAR�t','.�,uh
V
h mdred dollars 151001 or less.l
ceniiy that in the performance of the work for which this per
mit is issued. I shall not employ any person in any manner so as to
BUILDING
become subject to the Workers Compensation Laws of California.
Dote Applicant
t
-'
X ALTER OR ADD TO MECH. 4.00 4.�
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 4.00
PLAN CHECK
emplion. you should become subject to the Workers Compensation
Provisions at the Labor Code. you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=QF.M) 3.00
AIR HANDLING UNIT (OVER 10,000C.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
the performance of the work for which this permit is issued (See.
3097, Civ.C. I.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
I certify that I have read this application and stale that the above
VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction. and
PLUMBING
BOILER -COMP 13 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100.000BTUI SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, casts and expenses which
may in any way accrue against said City in consequence of the
X PERMIT ISSUANCE 3.003, 0
gran W g ofg of this pezit. F
MECH. CONT. LIC. NO.
84
MECH.
TOTAL
^I'•^f:
'f� TOTAL"_°,'
?.rkasR7 L, t_
7 00
.
Signature of Applin: /Contractor Da
OFFICE COPY