8645 j APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE ALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI F ION PERMIT NUMBER
AD
BUILDING APPLICATION & MIT 8645
on DIN
21771 Stevens' Creek Boulevard BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - PLAN CHECK VALIDATION
R*lneth Gilbeau & OTY. ELECTRIC PERMIT FEE
HONE
1 1
NAME OUTLETS UTLETS-SWITCHES-RECEP 10.00/1.00
W.L. HICKEY SONS, .11%.NO 95122 . LIGHTtNG.FIXTURES ' 10.00/1.00
CGNTRACTOB'S - APPLIANCES-RESIDENTIAL 4.00
A BOX
urnvale C612A09 40 736=4938 PANELS - 10.00 DATE OF APPLICATION
urn
ARCHITECT - - PANELS 200 AMPI 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
0C,NO. SIGNS TRANS. 3,00
ADDRESS eea - SPECIAL CIRCUIT: 5.00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 20.00
ior�ASET 13OX 61209 MOTORS SEE FEE SCH.
Sunnyvale, CA 94088 SERVICE CHANGE 20.00
_02 LICLNSLD CONTRACTORS DECLARATION TEMP.POLE 30,00 /
a v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w a vai
(commencing with Section ]000)of Division 3 of the Business and . BLDG. ELECT. PLG: MECH:
F v,z LicerPr.fissio la Cod ,cowl�siy license is in full forcegwl.eReGL ❑ ❑ ❑
2 O m - License Class •JO Lie.Number 9J1LG
o Z E w Date,5�3=85 C.atr.tnW.-L.$ICKEY-SO S,
w¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
A O s O . INFORMATION
w ;LL y J hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
r u o vt Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
m � Code:Any City orcomny which requires a permit to Construct,alter,
,le Q ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. - LIC.NO. ELEC.
iO u requires IIIc applicant for Such permit to file a signed statement that TOTAL PERMIT TO
w hs e Is licensed pursuant to the provisionof the Contractor's License
H i i Law(Chapter 9(commencing with Section]00()o(Division 3 oflhe L a
f 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
CE r es the basis for the alleged exemption.Any violation ol'Section 7031.5 STORIES TYPE CONSTR.
by:my applicant for a permit subjects the applicant uncivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not marc than five hundred dollars($500)J:
O 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sale compensation,will do the work,and the structure is not
intended or'offercd fur sale (Sce. 7044, Business.and Professions 8 DRAINS-FLOOR,ROOF,AREA,COND. 5.00 '
Code:The Co to ctor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work 15 FIXTURES-'PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided That such improve-
mentsarenotintendedurofferedTarsale.If,however,the building 1 GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he'did not build or inr 4 GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 �- BUILDING USE
prove for purpose ofsale.). RES IND CON , PB Due,
' - ❑ I,as owner of the property,am exclusively contracting with.
INDUSTRIAL WASTE INTER. 30.00 E] ❑ 0. ❑ ❑ -
licensed contractors to construct the project(Sec..7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 A55E550115 PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
Contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. 1 SEWER-SANITARY"TEA.20Oft/10.00 'TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,BA P.C.for tills 1 WATER HEATER / E T 6.00
reason
Owner Date 1 WATER SV$TS.00 - ACC.DATE ACC.FILE NO,
WORK ERS'COMPHNSA'I'ION DECLARATION WATER TREAE E IP, 5.00
1 hereby affirm that I have a ceril'Ica t,of consent to self-insure,.
or a certificate Of Workers'Compensation Insurance,_
or a certified CrIPPA1110 ZONING ENG.SITE NO.
copy the ( 7/�(�1C/ b.C. ,
PolicyNG (4. 041Fil )Western Emoltivers
0 0 . e ct(y is hereby furnished. ' -r FIRE SPRINK ENERGY T 24
Z zM, Certifiedo is filed with the city inspection,division.
o Appb-mW.I,._ff1CK& Y-SONS,-ING MISC.- REFER TO ORD. Y 0 N❑ Y ❑ N❑
CCN CE BIT FICATE Op E X 17M PTI ON ERO M WO R K 17 RSPERMIT ISSUANCE 10.00 PLOOOZONE A.L.U.C.
LU COMPENSWION INSURANCE - PLG.CONTR. LIC.NO. PLG.
0-
a( 'This section need not be completed if the permit is for OW L.Hickey SOnB Inc TOTAL ( � Y N Y [:] No
])."died'dollars($100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, I shall not employ any person in any mannerso as to
become subject to the Workers'Compensation Laws of California.
0 y Date Applicant - BUILDING"
} W NOTICE TO APPLICANT It,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F.. Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE '
U such provisions or this permit shell be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I.hereby affinli that there is a construction lending agency IOr EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name_RlimitOmO.-Blink Of' CnJif- s
Lender's Address�T�c -* ] -ti�.t�S$n.-J09e- HEATING UNIT(OV EA 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application uad state that the ahove VENTILATION FAN (SINGLE) 4.00
information is correct, I agree to comply with all city.and county BOILEfl-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING ordinances
ordinances and state Taws relating to building construction, and '
hereby authorize representativesthiscitysees enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection
tion purpos.
(We).agree to save, indemnify and keep harmless The City of MISC,- REFER TO ORD.
' Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10,00 CONST.TAX
may in any way accree.against said City in consequence of the
gmatingofthis permit. MECH.CONT. LIC.NO, MECH.'
,W.L. HICKEY SONS, INC., S rOTAL TOTAL
Signature ol'Applicant/Contractor Dale 13-85-
OFFICE COPY