C 7041 (2) APPLICANT TO FILL IN INFORMfkTION WITHIN RED 1LINES - USE BALL POINT PEN ONLY
. ' BUILDING PROJECT IDENTIFICATION - PE MITNUMBER
ITRUING APPLICATION & PERMIT
_ _ 7041
ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
1p93 fe Road
OWNER'S M . PLAN CHECK VALIDATION
NAME Nom' GTVA'a ' ..
VALLCO "ELECTRIC"PERMIT Y FEE'
PHONE
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
STOP-.FIRE, INC. LIG.NO 433114 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S REsS PPLIANCES-RESIDENTIAL 4,00
A
4�0 E. Brokaw Rd.PHONE 293-347 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6OO PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. / 3.00
ARCICR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDDRORESE ZIP EMP.METER OR POLE INS. 15.00
AMOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
0 0 o LICENSED CONTRACTORS DECLARATION S 1985
a v I hereby affirm that 1 am licensed made provisions mf Ch.plc,9 I NCE,DATE
y a N (commencing with Section 7000)of Division 3 of the Business and BLDG. E 6 AECH.
F w z Professions Code,and my license is in full force and effecL IIfILJI
z o w- Dmtc c5l� _ ],_],4-Ceit Number('_.I-(T_ 6_
z 0 o Date- Lic.Nuor`_/Yfr/ �{.�//- _f_
s • BUILDINGIPLERMI,,yyT--'
rtw
OWNER-BUILDER DECLARA"PION NINF.ORMATIQNR, s",
w a w I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
rc Y D VALUATION $/FT.a
H .0 a law for the Following reason.(See.703 I.S.Business and Professions PERMIT ISSUANCE - 6.00
E �A04 Code:Anycilyorcounty which requires a permit to construct,alter, ELEC.CONTE. LIC.NO.
Q a, ¢D Improve,demolish,or repair any structure,prior t0 its msuance,also ELEC. -
O¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO Q(��
d
Is " he is licensed pursuant to the provisions of the Contractor's License
Hzi
Law(Chapter It(commencing with Section 7000)of Division 3 of the ��QCr(-'Q�N •t
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE' v
othe basis for the alleged exemption.An,violation of Section 7031.5 ,�ES R.
i ;m by any applicant for a permit subjects the applicant tom civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500).):
❑ L 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 salt(Sec. 7044• Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
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 4.00 50.FT,FLOOR AREA TOTAL ACREAGE
himself a through his own offered
employees,Provided that such improve
himself
oncrus are through
et oremployeesale.provided
that such
building GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA) 100 BUILDING USE
builder will have the burden of proving Thal h . . .
e did not build of int- RES IND CON PB Dmar
prove for purpose It sale.). - INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
❑ 1,as owner mf the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:"I'he 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 cammemgs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ lam exempt dndcr Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK Ii RS'COMPENSA'TION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a mrtificatc ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified
copy thereof(See.3800.Lab.C.).
Policy No. Company
O ❑ Certified C py I hereby fur i5It d. FIRE SPRINK ENERGY T 24
`��p Cerlifiva�bvy f c sy�gly�,y 'I I division.
zZO n{,1, .:ve - 'W, ' cY ' misc.- REFER TO ORD.
v ❑ N❑ v ❑ N❑
F- y PERMIT ISSUANCE 6.00 vlooD ZONE A.L.u.c.
cc CER'I'IFICAI'I:01s EXEMPTION 17ROM KERS'
W _ COhIPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL Y❑ NE] Y❑ NF]
0 Z hundred doIIaO(SIOO)or less.)
U O I certify that in the performance of the work for which this per OTV. MECHANICAL PERMIT FEE FEE SUMMARY
IL H mil is issued,I shall nal employ any person in any manner sm as to
OUbecome subject to the Workers'Compensation Laws of California.
UJ O. Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 3J
} N NO'1'ICF "1'O AI'I'hICANT: 11,ul to making this Cert ilicutc of Ex-
H Z ungrtion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK ��. Q„3
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10000GF.M.) 3.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE vt�
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performmnce of the work for which this permit is issued(Sec. MICROFILM
3097.Cie.C.), HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATINGUNIT(OVER 100,000 B.T.U.)7.50 -
Lender's Address ELECTRIC
I certify that I have read this application and state(hat the above VENTILATION FAN (SINGLE) 3.00
mformates a correct.l I agree to comply with all city and county BOILER-COf H.P.or 100,000B.T.U.) 4.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby aulhorite representatives of this city to enter upon the BOILER-COMP (0.,IWOOOBTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
May in any way ucclve ago' sl said Ci y in consequ• Ix of the PERMIT ISSUANCE 3.00
gr:mti of this Permit MECH.CONT. LIC.NO. MECH. O9
y ` I TOTAL TOTAL OJ
SI at re of Appli t/ onlmctor D e
r OFFICE COPY