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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION
&PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
5669
BUILD AD.OrsGAPPLICATION
d.
20818 evCandie floor
20813 Stevens Creek Blvd.
NAMER s O mann s Sp
P-ce,252-7
k e k�uung,:, .y
>, 771N,77 ..�; ;
.;._ ,,. r4. r- .
PLAN CHECK VALIDATION
CONTRACTORS
peninsula Air Cond,L;Ng!. 436343
UTLETS-SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACT01690 Tacoma Wa , 415-
ADDRESS 1
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
1,Wdwood City, Ca. PH 9-18%0
GATE OF APPLICATION
ARCRITECT
OR
ENGINEER
uc. NO.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESSENc'
ZIP
SPECIAL CIRCUIT 5.00
'PERMIT VALIDATION
1l
-1
EMP. METER OR POLE INS. 15.00
APPLICANT '$
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
'/� %417
LICENSED CONTRACTORS DECLARATION
1 haehy affirm that I am licensed _mO,provisionsof Chapter9
I ournenclog with Section 7000) of Division 3 of the Business and
Pont ...ions Cn-sa Qty lieensp is In lull 4rtg3'I�c3
LIUY 1152 CIOU' IC. Nlmlgqeeff
nate - ontracloi"Pn
ISSUANCE DATE
BLDG. ELECT.
❑ ❑
PLG. MECH.
❑
,'"'�.:,, BLIIL0INO,P.ERM "- '
?`?
OWNER -BUILDER DECLARATION
MISC.- REFER TO ORD
harsh infirm that I um exempt Iron the Contractor's License
Lawforthefollowing
nry which re Tir LS,emit toccud Professions
permit Coto issuance. also
Cope: Any city or county which structure. prior In its issuance, also
improve, demolish, or repair h p rmit to file
for such permit to file a signed actor's nt that
,quires the d pursuant
h Is II rpt. pt coo to In provisions of the Contractor's Lice3 ofthe
Law lesanti 9lcommentmgwithr that h is exempt
pt theref o Ed
tBusiness- a I he alleged Cod 1 r that he is exempt ectio mm and
lhr. basis for the alleged exnmp[ion Any violation DI Section 7031 $
f 4','LL'1NIINFORMATIONkE"Li;
VALUATION
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO. ELEC.
TOTAL
ERMIT TO
Y. a' `
OTVL i t =t, -d 5vy ,.PLUMBING; PERMI?'N" •P.} { e FB '^a
L r'°dl k A, p '"jl . - ,:rp'�'� - y�'�i.,
STORIES
TYPE CONSTR.
by any applicant for a penin subjects the applicant tun civil penalty
of not more thin live hundred dollars (8500).)'.
ALTER -DRAIN & VENT -WATER (EA.) 4.00
O I, as owner of the property, or my employees with wages as
::. it .ole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 4.00
innnded or offered for sale (Sec. 7044. Business and Professions
Code. The Contractor's License Law does not apply to an owner of
property wno builds or improves thereon, and who does such work
himself or nohis own employees, provided that such improve-
mentsare not intendedorotrered for sale. If, however, the building
FIXTURES - PER TRAP 4.00
50. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement is sold within one year of completion. the owner-
builder will have the burden or proving that he did not build or im
prove for purpose of sale.L
❑ h as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUIL ING u E
RES IND CO PB Onner
El
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construct the protect (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to in owner of property who builds or improves thereon, and who
LAWN SPRINKLERS -I INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 IEA.) 1.00
ASSESS(142*SrRCEL NO.
-
contracts for such projects with a cuntracrods) licensed pursuant to
the Contractor, License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ I am exempt tinder Sec. , B.&BC. for this
reason
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM 4.00
ACC. DATE
ACC, FILE NO.
WATER TREATING EQUIP. 4.00
WORKLRS'COMPENSAT'ION D17CLARATION
I hereby affirm that 1 have a certiticate of consent to sell -insure,
or a ceridicale of Workers Compensation Insurance, or it certified
ZONING
ENG. SITE NO.
t' ,** ItI12VQ;�%Iplremont Ind. Vo.
Certified copy is hereby furnished.
Certified copy is Bled with the city inspection division.
Applicant
FIRE SPRINK
Y ❑ N�
ENERGY T-24
Y [:] N�
MISC. - REFER TO ORD.
CERTIFICI'I' E OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOOZONE
A.L.0 C.
PLG. CONTR. LIC. NO,
PLG.
TOTAL
COMPENSATION INSURANCE
This se,fibm need not be completed if the permit is for one
Y N
v N
- m fY s, -'T xt b W' �„� %
CITY I MfiCNANICAL•` PHRMIT*s,'µT}v'-EtiFEB�'
tta ,•< t y_ i,,, 1E _itx 3 I
-
�.r.ia_#
-}'IPE„
'y
R1ity
hundred dollars lS 100)... less)
I pity that m the performance of the work for which Ihns per
l t 's issued I shall not employ any person in any mannerso as to
hero nc subject to the Workers' Compensation Laws of California.
Dale_ Applicant
BUILDING
X ALTER OR ADD TO MECH. 4.00 4, Q
NOTICI7 TO APPLICANT. If, after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
APPLIANCE 4.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10D000.F.M) 3.00
AIR HANDLING UNIT(OVER I0,000CP,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 (Sec.
3097, rv.C).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
H EATI NG UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Nome
Lender s Address
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
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER -COMP 13 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000BTU)SEE FEESCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in copseyuence of the
gra g of this p rmice
1 21 8
/ /
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. N0.MECH.
TOTAL
?';, .,rc ip 1+;1<.+
n,,a._ '.t.4 a �
TAU
`*N`.,a'f�'`. 'r
7.00
nate re of Applf nt/Contrue torate
OFFICE COPY