6164 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
�. BUILDING PROJECT IDENTIFIC N" - - PERMIT NUMBER
'
1
BUILDING APPLICATION,&;PERIUi1T 616 4
DRESS
J_ pD217/n0 Stevens Creek' Boulevard
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNERS - PLAN CHECK VALIDATION
• NAr.9lenneth �Gilbeau & OTY. ELECTRIC PERMIT FEE'tallo=a -
f� PHONE - 0'
CTOR'S 5.00/1.00
'
VANE UTLETS-SWITCHES-REC_EP '
NAME
W.L. H1Ckey '$OnB s 1iR9eO .95122 . LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
"CF' t5. BOX 61209 _ PANELS
A. x*5.00 DATE OF APPLICATION
ARCHITECT SIGNS - 6.00 PLAN CHECK FEE P.C.NO.
o0 ' ., -
ENGINEER
• � UC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. - PERMIT VALIDATION
ADDRESS - SPECIAL CIRCUIT 5.00 _
ZIP rrEMP.METER OR POLE INS. -15.00 -
APPucn�xr., MOTORS SEE FEE SCR. e �
ALRIEVBox 61209.
SERVICE CHANGE. 10.00
Foo hICIiNSF.0 CONTRACTORS DECLARATION �O/(f,�
a wo U I hereby affirm that I am licensed under provisions of Chapter 9 ISS ANCE DATE
H G va (commencing with Section 7000)of Division 3 of the Business and - - BLDG, ELECT. .PLG. MECH.
F y z I'rofessinns Cos• 99�s1 my license is in full fore t.
Z: O w- Liccns la' - O Lic.Numb -
F w Uatc Contractor.___.!.
a Y 010 10
BUILDING PERMIT
� ¢ OWNIiR-BUILDER DECLARATION
o a u . - INFORMATION
w ; LL ,- I hereby allinn that I am cxompt from the Conlraclur's License MISC.- REFER TO ORD
FLLm4 Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 VALUATION 5/FT.
Code:Any city or county whid,requires a permit to construct,alter,
2 a a p improve,demolish,or mpair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
in
D IC requires the applicant for such permit to file a signet statement that TOTAL •'�
n w m" he is licensed pursuant to the provisions of the Contractor's License �`PERRMITT TO,
I-zQ
Law(Chapter 9(commencing with Section 7000)ofl)ivisian 3afthe
s i D Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE ,
is F �� the basis far the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
w. by any applicant for a permit subjects ore applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500)):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE , OCC.GROUP, .-RES.UNITS
'their wle compensation,will do the work,and the structure is not ,
intended or offered for sale (Sec. 7044, Business.and Professions DRAINSrFLOOR,ROOF,AREA,COND._4.00
Code:The Contractor's License Law does not apply to an owner of -
propertywhobuildsorimprovesthemon,and who does such work 1,'t. FIXTURES--PER TRAP 4.00 y SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building Z. GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- r J s> -
�I GAS EA.SYSTEM-OVER 4 (EA.). '1.00 BUILDING USE
builder will have the burden of proving that be did not build or ire-
Prove For Purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON 'PB Omer
❑ I,as owner of BIi property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
f sensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-Z INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Conlractoi 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 contractor(s)licensed pursuant to 1
the Contractor's Lwetoo Law. - SEWER-SANITARY-STORM-,EA.200R/8.00 TRACT NO. PARCEL NO.
❑ I ana exempt under Sec.-.BAP.C.liar.this 1 WATER HEATER W/VENT 4.00
reason
Owner Date1 WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAfION DECLARATION WATER TREATING EQUIP 4.00
mm I I hereby al Nrm that I have awrtifi vle of consent to selhinsure: _
or a certificate(if Workers'Compeasalion losurance,ur a[ertil iesl ZONING ENG.SITE NO.
csipy thcn'w(1!H'j V
_ I•olicY Nn.qqj.,qq'T[[��Yumpaiy Western-Employe-rs- •;•
Q .Ll Cer1HlNshtipp is hereby tarnished r I y FIRE SPRINK ENERGY T-24 - -
Z,Z 'Ago Certified copy is fled with the city inspection A �S,91. - - '
6.00
O ApNicam1i[.L_-.H1GKEY-SONS ING, MISC.- REFER TO ORD. Y E] N E] Y ❑ ❑
,N
!rN CIiRTIPICA'hE OI'IixliMPi'ION FROM WORKERS' PERMIT ISSUANCE � 'FLOOD ZONE, A.L.0 c.
Ill 2COWTNSA'f10N INSURANCE COI TR I�IC.NO. PLG,
Ifhis sectidn acct not be completed if the permit is for one •�•Hicnkey Sons .LnC 95122 TOTAL 12,00 Y❑ N❑ Y ❑ N❑.
Z hundrr l dolhus(S 100)nr[us.) - ' '• -
L O 1 certify plat in [be performance of the work fo'*mUch this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY -
LL I- mil is,issued,I shall not employ any person in any manner so as to
O W become subject to the Wlirken'Compensation l:uws of Calll'ornin. I - BUILDING -'
n Date Applicant ALTER OR ADD TO MECH400
} to NOTICE'f0 APPLICANT: If,after making this Certificate of fix-
. .
F.Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK'
provisions of lite Labor Code,you most forthwith comply with FEE
L) such provisions or this permit shall he deemed revoked- AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,0ODC.EM.) 5.00 SEISMIC FEE
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,CP.C). - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name_Sumi_tomo_Bank-of ra14_f.- HEATING'UNIT(OVER 100,000 B.T.U.)7.50 /
Leader's Address-51l �t St.Sana-Se- ELECTRIC
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.I agree to comply with all city and county BOI�EA ,p(3 H.P.Or 100,000 B.T.U.) 4.00 PLUMBING /o
ordinances and state laws relating to building construction, and
'x hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP IOr l00,0008TIi15EE FEE SCR. MECHANICAL
I .
ve
(We)•agrec to save, indemnify and keeli harmho , the City of MISC.- - .REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against wid'.City in consequence of the 'PERMIT ISSUANCE 3.00 -
granlingofthispermit., ` MECH.CONT. UC.NO. . - MECH.
U1r.l.._1�7 S^3'85 TOTAL TOTAL
Signature Rpt o t/(, C• Date - s
OFFICE COPY