8618 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT(FICATION PERMIT NUMBER
BU AN APPLICATION & PERMIT 8618
ADDREBa -INP LOT 15
_ . BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
O E 'S PLAN CHECK VALIDATION
NAME DeAnza Group, A California QTY. ELECTRIC PERMIT FEE
PHONE
rCieme AcroRsnrtnprn" OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORPPLIANCES-RESIDENTIAL 4.00
'SADDRESS411 Sorel Ave,Ste. 410
Ran Matpcf� HO PANELS 10.00 DATE OF APPLICATION
OARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
IC.ND. SIGNS TRANS. 3.00 ',
ARCH,es ENG' SPECIAL CIRCUIT 5.00 PER TION
2070 Business Ctr. #220
zIPEMP:METER OR POLE INS. 20.00
APPLICANT'
ADDRESSS 411 Sorel Ave, Ste. 410 MOTORS SEE FEE SCH. 'JUL 2 9 1985
SERVICE CHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
a u w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m rt v`i (commencing with Section 7000)of Division 3 of the Bu iness nd BLDG. ELECT. PLG. MECH.
H D z Professions Code,and my license is in full force an a fee ❑ ❑ ❑
License Clasg Lic.Number
mr °w Date j/ Contractor
a Y E J BUILDING PERMIT
¢ a OWNER-BUILDER DECLARA ON
E. o o u INFORMATION
w 3 LL H 1 hereby affir f that I am exempt from tire Contractor's
License MISC.- REFER TO ORD
LL Law¢ Law for the following reason.(Sec.7031.5,Businessand professions PERMIT ISSUANCE 10.00 VALUATION SIFT.
rN Code:Any city orominty whichrnluiresapermil lotonomel,alteq
ar ¢ ¢ p
d improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL ERM IT TO
hw m e is licensed pursuant to the provisions of the Contractor's License j
ic z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the V•
x a Business and Professions Code)or(liar he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u3m by any applicant for a permit subjects the applicant lou civil penally ALTER-DRAIN -WATER (EA.) 5.00
of nol more than five hundred Aollurs f 55001.1: ��
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECTDEVICE 400
their sole compensation,will do the work-and the structure is not . .
OCC.GROUP ES.UNIT
intended or offered for sale (See 7044, Business nid Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code. The Contractor's License Law docs not apply to un owner of
property who builds of irlpmvcs thereon,v0A who does SlrCll work FIXTURES-PER TRAP 5.00 SO,FT.FLO R AREA TOTALACREAGE
• himself or through his own a nployees,provided that such i"tPoles-
meats are not intended or offered for sale,if tirehowever, building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 ILDING usE
builder will have the burden of proving that Int did not build or i"r
prove for purpose of sale). IND WASTE INTER. 30.00 IND CON ve other
❑ Las owner of the property,am exclusively contracting with 0 0 0
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions C'ude:The Contractor's License haw 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 m
the Contractor's License Law.' - SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
real❑ I um exempt under Sw. ,B.&P.C.for this WATER HEATER W/VENT 6.00
non
OwnerDmc WATER SYSTEM 5.00 ACC.DATE' ACG FILE NO.
W'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate Of ea"war to elf-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof IS 3800.E A I � I
policy No
❑ Cerlll�.+ turn 1 � FIRE SPR INK ENERGY T24
Z Z Cq CertifeJ copy Ie a city inspection division. MISG- REFER TO ORD. -T
O AppTca"t V ❑ NEJ V iJ N[3
ir y CERTIFICATE 1'E I'MPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.u.C.
W > COMPENSA-f ION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL a (This section need not be completed if the permit is for one. TOTAL
Y N v N
hundred dollars IS 100)or less.)
U O
I certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any perste many manner so as In
O Ubecome subject to the Workers'Compensation Laws of California.to
S`
G. Dute Apphca"( ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT': IL after making tills Certificate of IN-
E F 2 caption,you should become subject to the Workers'Compensatiou APPLIANCE 5.00 PLAN CHECK
U suchrprovisionsthe
of this bper nH shalr Code, l be created revokedcomply with AIR HANDLING UNIT(TO 10=C-F.M.) 4.00 FEE
CONS'fRUCT10N LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the permOranee.of the work for which this permit is insued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Ndamo
e Rank f Amprira, P.O.
Lender's AdresHEATING UNIT(OV ER 100,0008.T.U.19.50 ELECTRIC
s'
r ytha.-
Icertifylhmlh�a� hdthisapplicati�nand tlreabove 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 authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTUI SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree t Save indemnify and keep hmmless the City of MISC.- REFER TO ORD.
Cupertino affair a lilies,jtgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in cry cc uc it" said City in amscq uencc of(he
granting of(hi p I tit x„ MECH.CONT. LIC.NO. MECH.
oyAJ5/31/8 TOTAL TOTAL (ij3
Signature of Applic nEContra for Datc
INSPECTOR COPY