14193 (2) As
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION ' PERMIT NUMBER
ADDSESS APPLICATION & PERMIT 14193
A21170 Rainbow Dr. Lot #3 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'$ PLAN CHECK VALIDATION
NAME DTV. ELECTRIC PERMIT FEE
The Gregory Group PHGNE 595-2100
NAAMERAcrGRs UTLETS-SWITCHES-RECEP 10.00/1.00
Central Service CO. LIC,No. 171537 ILIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
`6255Charles Street PHONE 298-0556 PANELS 10.o0
DATE OF APPLICATION
RRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
nooni
ss ENG. baly
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zap TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
Al
APPLICANTS
625 Charles St, SJ 95112 SERVICE CHANGE 20.00
0 o a
'l'' LICENSED CONI'RACTORS DECLARATION
a v w I haul-]l3artaef7l am licensed ambeenGiIVEhaf CBeTV L.e
y a a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PL MECH.
Professions CodF.ana{�y license is in full force IRd ffoat� ❑ ❑ ❑
Z o�, License Classy-,3S�Lic.Numher
y Date 1_1 13-87-Con traeteCentr-al-Ser-vi e
¢ ¢w a OWNISR-fl UILUER DIiCLA RATION BUILDING PERMIT
s o A O INFORMATION
w g LL N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
H a-o a Law for the following reason.(Sec.7031.5,Businessand Professions PERMfT ISSUANCE 10.00 VALUATION $/FT.
i vs Code:Any city or county which requires a permit to construct,alter,
¢ S¢Q improve,demolish,or repair any struCILre,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
to K 0¢ requires the applicant far such permit to file a signed statement(hal TOTAL
n
is m" he is licensed pursuant to the provisions of the Contractor's License PERMIT T
Law(Chapter 9(commencing with Section 7000)of Divlsloa3 often
E ¢ er Business and Professions Code)or that he is exemn,pt lhouefR and OTY. PLUMBING PERMIT FEE
It $ the basis for thealleged exemption.Any violation.1 Section 7031.5 STORIES T PECO SEE.
T by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($5001)
❑ I,as owner of the property,or my wol yecs with wages:, -BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and tire'streahva is not
Intended or offered for sale(Sec. 7044, BLISdaeaa and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 ---
himself or through his own employees,provided that such improve- 12 50.FT.FLOOR AREA TOTAL ACREAGE
ments are not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or inn- BUILDING USE
prove for purpose ofsale.)' INDUSTRIAL WASTE INTER. 30,00 RES IND CON Pa Omer
❑ 1,as owner of the proparly,am exClasivCly contracting with El 1:1 El ❑ El
contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law docs not apply V.B.. .
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects will,a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA,200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under See.-,R&P.C.for this1 WATER HEATER W/VENT 6.00
reason ---
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified - ZONING ENG.SITE N0.
colicbit. IF055�iy),Lab.c.).pacific Comp.
Policy N!1'. mpany '
O ❑ Certified copy is h rcIT fu fished. FIRE SPRINK ENERGY T-24
Z Z �( Cert lfi op i fel Ih fire cit r -i division.
F p Applicant MISC.- REFER TO ORD. Y ❑ N❑ v ❑ N❑
X N CERTIFICATE 01:EXEMPTION FRO YORKERS' PERMIT ISSUANCE 10.00 --- FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTE. LIC.NO. La
CL O (This section need not be completed if the permit is for one Central Service 17153 OTAL --- V❑ IN F] Y❑ ry❑
0 Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work tier which this per- OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
0 do mit is issued,1 shall not employ any Personin any so as to
O become subject to thW'
e nrkcrs of Cali Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of lix-
Z emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C..1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10A00C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is aconstruction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
-� I certify that 1 have read this application and slam that the above 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-OOMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this
this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned properly lot inspection purposes.
(We) agree to save, indemnify and keep ha nn less the City of MISC.- REFER TO ORD.
Cupertino ag ins, liabilities,judgments, costs and expenses whichCONST.TAX
may In any ay accrue against said City In consequence of the PERMIT ISSUANCE 10.00
SO iog Uf is per, L % MECH.CONT. LIC.NO, MECH.
11-13-87 TOTAL TOTAL
R, ore of Applicant/Contra r IJ;Oc
OFFICE COPY