09578 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
" T
BUILDING PROJECIDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT ' On 7
ADDRESS ' ' `�' I
7C)
Orange Blossom- BUILDING-- ELECTRICAL-PLUMBING-MECHANICAL
OWNERS - - PLAN CHECK VALIDATION
NAME OTV. ELECTRIC PERMIT - FEE -
� Mr. Rex Glildby PHONL984-0360
• CDNAME /1,.rRACTos UTLETS-SWITCHES-RECEP 10.0000
Atlas Hetting UC.No.46 266. LIGHTING FIXTURES 10.00/1.00
ADoRs
ADDRESS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
1 Commercial Ste PHDNE O 16 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
O
OR
ENGINEER s ,
' ruc.NO ISIGNS TRANS. 3.00
ARCH.OR ENG. ISPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S ' �J
.' ADDRESS MOTORS SEE FEE SCH. /V
x' SERVICE CHANGE 20.00 ' , /
o o LICENSED CON'T 'RACTORS DECLARATION TEMP.POLE 30.00 �/ �l � -
u I hereby affirm that I dam licensed under provisions of Chapter 9 ISSUANCE GATE
a a n (commencing with Section 7000)of Division 3 of the Ilusiness and BLDG. ELECT. PLG. MECH.
H
F
i Professions Code,�A 2iii, V(cense is in full for4p
o M License CLie Numb-r
❑ ❑ ❑ ❑
o Z r w Duce�� ConTmctor�tla8-Heat
BUILDING PERMIT -4
¢ ¢ wa
OWNER-BUILDER DECLARATION - "INFORMATION '- 1�,}
o e_ O MISC.- REFER TO ORD
X ; N 1 to,the
affirm that I sm exempt 031.5 The Contractor's License
'0 o4 Lawforthefollowingreason.(Sec. uires a,ermit tocand Professions PERMIT ISSUANCE 10.00 VALUATION
ce - Code:Any city sh,or my which structur a permit o its issuance,
ce,her,
¢ Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
- 0¢ requires the applicant for such permit to file a signed statement that TOTAL - PERMIT O .
a es LL he is licensed pursuant to the provisions of The Contractors License
Le Law(Chapter 9(commencing with Suction 7000)of Division 3 ofthe
- < Business on
and Professis Code)or That he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ t$ the basis for the alleged exemption.Any violation Of Suction 7031.5 STORIES TYPE CONSTR.
a ; by any applicant for a permit subjects the applicant to a civil penalty' ALTER-DRAIN -WATER (EA.) 5.00
of not more Than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure Is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONE). 5.00
Code:The Contractor's License Lew docs not apply to an Owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SG.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,fors.provided that such improve-
mcuts r�mselfo through
riughhis or own efurudfeesale.lf,ed that
s(he building GAS-EA.SVSTEM-11NC.40UTLET$ 6.00
40 or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON PB Omer
prove for purpose of sale). INDUSTRIAL WASTE INTER. 30.00
Cl 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct The project(See. 7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The COntmClor'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 Contractor's License Law. SEWER-SAN ITAR V-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
Ieaoa
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPFNSAT10N DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I Imvt a certificate of consent to self-insure. ZONING
or a certificate�foff.,W��orkers'Compensation Insurance,or a certified ENG.SITE NO.
if
PrcYNO V9' Allied Pacific
O ❑ Certified copy is hereby furnished. FIRESPRINK ENERGY T-24
Z Z 70 Ccrtific yfy�y Is d t 05e city inspection division. MISC.- REFER TO ORD.
O Applicant�TtlSfl�i@S�g Y❑ N❑ Y ❑ N❑
c N Cl:R1'I FICATI:OF Ii XFSIPTION FROM WORK[SRS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSA'T'ION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ NEI
0 (This Section need not he completed if the permit is for one TOTAL
::) Z hundred dollPrs(8100)or less.)
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE -FEE SUMMARY
LL.H mil is issued,I shall not employ any person in any manner so as To
O
U become subject to the Workc,x Compensation Laws of CuliWnna. v
. .
0. . Dale Applicant ALTER OR ADD TO MECH. 500 BUILDING
} So NOTICE TO APPLICANT: If,after making this Certificate OFF",
F 2 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 shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOMC.F.M.) 6.00 SEISMIC FEE
hereby ul'I ism That entre is a construction lending agency I'or EXHAUST HOOD(WITH DUCT) 5.00
0Cperl'ormance of the work for which this permit is issued(Sec. HEATING UNIT IT 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.L 1 8 00
Lender's Nene HEATING UNIT(0 VER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the'ahove VENTILATION FAN-(SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorio, representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE F SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER ORD.
Cupertino against liabilities,judgments. costs and expenses which CONST.TAX
may in any way accrue against mid City in consequence of the PERMIT I UANC 10.00 lO�OO
gr' g 11 •m Q r MECH L .N . TOTAL
�L pp -a�$� Atlas Heating 46$266 18.00 TOTAL
5 arc ofA licam Corrraclor Data
OFFICE COPY