8630 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
'I t BUI LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
RmLDING APPLICATION & PERMIT
DRESS PLALOT 23
.- _.� It -7 PLAN 2 BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWN ^ PLAN CHECK VALIDATION
8630
NAME DeAnza Group, A California CITY. ELECTRIC PERMIT FEE
ONE
NOMERAcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
The Alden Company LIC.NO. 465640 LIGHTING FIXTURES 10.00/1.00
CONTRA
ONT ADCREACro
AR's 411 Sorel Ave,Ste. 410 APPLIANCES-RESIDENTIAL 4.00 San
Mateo. a 94 2PH 415 571-14 1 PANELS 10,00 DATE Of APPLICATION
ARRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
d o -NakamuralCNO C013712 SIGNS TRANS. 3.00'
ARCH.OREND, PERMIT VALIDATION
ADDRESS 2070 Business Ctr. 9220 SPECIAL CIRCUIT 5.00
Irvine. Ca. zIP 2]1S EMP. METER OR POLE INS. 20.00 )
APPLICANT S MOTORS SEE FEE SCH.
ADDRESS 411 Sorel Ave, Ste. 410
San Mateo, Ca. 94402 SERVICE CHANGE 20.00 ¢' y (�(
woo LICENS17D CONTRACTORS DECLARATION TEMP.POLE 30.00 Q/�o/Q )
a i w I hereby affirm tlmt I am licensed under provisions of Chapter 9 tSSUAN CE/OATS
Gem (commencing with Section 7000)of Division 3 of the Rusin es and BLD ELECT. PLG. MECH.
H w Z 1'rofessions Code,and my license is a full forte I
¢Zra wO—
Y¢ Hf.o—� License C>F $ _Lic.Number
r
( t
g TCntactor El ❑
Date_ BUILDING PERMIT
OWNER-BUILERICLARA I INFORMATIONoU
❑
X 3 u m 1 hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
u_ o< Law for the following reason.(Sec.7031.5.Business onJ I'ndessions VALUATION $/FT.
_ 0 PERMIT ISSUANCE 10.00
iw Code',Any city or county which requires a permit to construct,
¢ u, Q 0 improve,demolish.or repair any structure,prior to Its Issuance,aISU ELEC.CONTE. LIC.NO. ELEC.
n wD¢ requires the applicant for Such permit to file a signed statement that TOTAL PERMIT TO
re he is licensed pursuant to the provisions of the ContR¢tar,License
H Z i Law(Clmptcr9(contmmeingwithSection 7000)x(Uiviei"n3cfthe
¢ o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ I-m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE C'O'N/S'TIR,
a by any ctamethal for apemiltsubjects thaapplicanttoacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than lira h email dollars the applicant
.1:
❑ I,as Owner,of the property,or any employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves diction,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees,provided that such improve-
ments o shunterhis or offered for esale.rove ed thathOwever,suhebudding GAS-EA.SV$TEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,life owner- GAS EASYSTEM OVER 4 (EA.) 200
builder will have the burden Of proving that h - . - . .
e did not build or im- "BUILDING USE
prove fur purpose ofsaleJ. INDUSTRIAL WASTE INTER. 30.00 RES IND CDN PB Other,
❑ I,as owner of the property,sal exclusively contracting with El El 1:1 E]licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B: 6,00 ASSESSORS PARCEL No.
and Professions Code:The Contractor'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 LOT smell projects with a contracterts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Low. TRACT NO. PARCEL NO.
❑ 1 ant exempt under Sae. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Die WATER SYSTEM 5.00
C.oA7.t ACC.FILE NO.
WORK ERS'COM PENSA'F ION DFCLA RATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers Compensation Insurance,or a certified
copy thereof(Sea 3800,Lab.C.).
Policy N0._ h) "}den—Compan a
O ❑ Certs L y y'fun FIRE SPRINK ENERGY T-24
Z 2 f$Certified top I F w' the city inspection division.
O App mart MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
~ rn PERMIT ISSUANCE 10.00
— C1iRTlPICA'I':OP i%Eft PTION FROM WORKERS' FLOOD ZONE A.L.UC.
W > CONIPFNSATION INSURANCE PLG.CONTE. LIC.NO. PLG,
Q. aQ. Z (This section need not be completed if the permit is for one TOTAL Y 11 NEI NEIY❑ N
hundred dollars IS 100)or Icss.)
U O 1 cerlily that in the performance of the work for which this per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
1 LL U mit is issued. I shall not employ any person in any manner w as to
U W become subject to the Workers'Compensation Laws of California.
Q. Date Applicant ALTER OR ADD TO MECH. 5.00 . BUILDING U
t } m NOTICE TO APPLICANT, If,alter making this Certificate of 1;
F Z emplim,you should become subject to the Workers'Conlpeasatioa APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be dcemcd revoked. AIR HANDLING UNIT(TO 10,000CF.M.) 4.00
t CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE 71
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the pada nnan ce of the work for which flue permit is issued(Sue - MICROFILM
3097,Cie C,). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name Rank of America, P.O. HEATING UNIT(OVER t00,0006.T.U.19.50
Leaders Address_$e �.BgT� ELECTRIC
'Icert'ifythatlhovercod this applicat!0udta ttthC aba,, VENTILATION FAN (SINGLE) 4,00
• ialbrn ftm. 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 acth.ri,c representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection pu Dioses.
(We) a)agm
sav , iaJ em ify and keep harmless the City e-1' MISC.- REFER TO ORD. p -
Cupertinot Iia Rifles,j dgments, costs and expenses which CONST.TAX ,�/may in auC he aga st said City in consequence of the PERMIT ISSUANCE 10.00 `^granting om' MECH.CONT. LIC.NO. MECH.
5/31/8 or"` TOTAL
Signature ofWppN1a t
[ onU Date
INSPECTOR COPY