2607 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN OIV
P BER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT r� �+ O 1�
ABUILDING DRESS O 0. - G 0 I
ADaREN511000. N. .Wolfe Rd.
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S +-•' -fn�p. '`:{ - = PLAN CHECK VALIDATION
NAME
Hewlett Packard OTY. ELECTRIC PERMIT
I PEE'
PHONE
NAME oOUTLETS-SWITCHES-RECEP 5.00/1.00
NAME1u �-!o fz aUP'IA`IlL
S ►.Y , Cy LIC.NO. l I LIGHTING FIXTURES 5.00/1.00
CONTRACT s ,�� PPLIANCES-RESIDENTIAL 4.00
/ AOORE55 _ZO6 S �. (� gLcN�.M1?- •0 �.y�
JIM I L. 1 ` 4 Sj0 J J PHONE 94LP'/ 2/L PANELS 5,00 DATE OF APPLICATION
ARCHITECTSIGNS 6�
ENGINEER PLAN CHECK FEE P.C.NO.
OR
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALI DATION
ADDRESS
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT's
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS DECLARATION /
m u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
uaHi
as wI (commencing with Section 70001 of Division 3 of the Business and BL ELECT. PLG. MECH.
z< Professions Codeyld ply license is in full forcq a114+(f 1 tl ❑ ❑ ❑
, 00.- License Class G /Cr Lia Number 1 'f ']
9 0 Date 5- - *1 Contractor
• 6 I - 'BUILDING PERMJ
w u OWNER-BUILDER DECLARATION r,t. ,ORMATION;wt-; f,J
oa. MISC.- REFER TO ORD -
w ;a w I hereby affirm that I am exempt from the Contractors License VALUATION WFT.'
F = D a Law far the following reason.(Sec.7071.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter, aq�(yg l zs ry
cG¢ FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ssz y e
i ram requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$u- he is licensed pursuant to the provisions of the Contractor's License _ ,,;v„P,- .o . F
H z a Law(Chapter 9(commencin with Section 7000)ofDivision 3 ofthe '£" I e Sprinkle
Business and Professions Code)or that he is exempt therefrom and G7Y. PLUMBING PERMIT •}• FE&� A P
r 0 the basis for the alleged exemption.AnY violation of Section 7031.5 a -' .,.t-. - i'' is • « ei J. .,7+ r'1 .",- a nIPY: STORIES TYPE CONSTR.
i ;$ by any applicant for a permit subjects the applicant toacivilpenalty , ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(3500)):
❑ I,as owner Of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure Is not ,
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve• GAS-EA.SYSTEM-1 4.00
ments are not intended or offered for sale.If,however,the building
' or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE IN
builder will have the burden of proving that he did not build or im- RES D CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ ],as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed cantracton to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cade: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 projects with a contractors)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec. ,B.ffiP.C.for this WATER HEATER W/VENT 4,00
re Son
Date Owner WATER SYSTEM 4.00 ACC.DATE ALC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate,of Workers'Compensation Insurance,or a certified
copy the fr -MiCo Lab.C.lMatl- /"�.dlx� MIS
Policy a Company KK MMTT V'GJl' ' , `srsl
0 C! ifiedc is hereby I urmshed. FIRE SPRINK ENERGY T.24
Certified L pY is filed with the city inspection division. MISC.- REFER TO ORD.
Z 0 Applicant Y ❑ N❑ Y ❑ N❑
Fy F PERMIT ISSUANCE 6.00 FL000 ZONE A.L.
cc C TI IC E F EXEMPTION FROM WORKERS'
LU 5 COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG,
CIL C1 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
=) Z hundred d011ars(SIGO)or less.) p Cc p ) rG + A t
U O I certify that in the performance of the work 1'ar which This per- QTY. MECHANICAL PERMIT' i �`P� 'FEE y "lir 4 7 `FEE SUMMARY(
LL F- mit is issued,1 shall not employ any person in any manner so as to / , L - 1 y ,, K
U become subject to the Workers Compensation Laws of California.
0 y DateApplicant ALTER OR ADD TO MECH. 4.00 Y BUILDING 62.50
} res NOTICE TO APPLICANT: If,after making this Certificate of Ex-
I- ? emption,you should become subject to the Warkers'Compensation APPLIANCE 4.00 PLAN CHECK 1.
provisions of the Labor Code, you must forthwith comply with FEE - 40.63
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 101000GF.PA) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p000.EM.) 5.00 SEISMIC FEE 0.
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. MICROFILM
3097,Civ.C.). HEATING UNIT(T0 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lenders Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating 10 budding construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
' hereby authorize representatives of this city to enter upon the BOILER-COMP to.,100,000BTUISEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(Wel agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, cost, and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
ma m any way accrue against said City in consequence of the
gra U o"this pe it. - MECH.CONT. LIC.NO. MECH. pj �?• {;. ',l,:y'
/ IO_ TOTAL 4'T 63
Signature ol'App moat/Contractor Date 'y•ry" .t_ .i,+y-rtw{ 103.63
OFFICE COPY