8615 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT'PEN ONLY
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
-_vim � auILOINc 78�(o LOT 18
'IrOORE55 8615 r
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL ux YV�
PLANCHECK VALIDATION
NAME DeAnza Group, A CaliforniaOTY. ELECTRIC PERMIT FEE
• ONE
CONTRACTOR'S
-NAME OUTLETS-SWITCHES-RECEP 70.00/1.00
41C.No 465640 LIGHTING FIXTURES 10.00/1.00
caCTORs PPLIANCES-RESIDENTIAL 4.00
AnnRE
SS 411 BOrel Ave,Ste. 410
PHO PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 "PLAN CHECK FEE P.C.NO.
OR
ENGINEER
IC.NO, C013712 SIGNS TRANS. 3.00
ARCH
sOR ENG. SPECIAL CIRCUIT S.QQ PEP 9t. ATION
2070 Bueineea Ctr. $220 P
zuP92715EMP. METER OR POLE INS. 20.00
APPuc9RTs MOTORS SEE FEE SCH. L 291985
ADDFES$ 411 Borel Ave, Ste. 410 JU
Ran Maii-An. ea. 94402 SERVICE CHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City Of
¢ va v Cl O
ffIOOI hereby affirm that I am licensed under provisions ofCha ter9
Z ISSUANCE DATE
As
(commencing with Section 7000)of Division 3 of the Busme s and BLDELECT. PLG, MECH.
D z Professions Code,and my license is in fa Nmnfill]force a deject.
El E] ❑
z 0 u, - License Clas Liber
g Z�_ea Date R�3-1 BS Contractor
Q y E J
a a OWNER-BUILDER DECLARA BUILDING PERMIT
a a INFORMATION
X
g;u. m I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
. 0 O J Law for the following reason, 7031.5.Businessand Professions pERMIT ISSUANCE 10.00 VALUATION $/FT.
Code.Any city or county which requiresa permit to construct.alter,
IFin Q improve,demolish,or repair any Structure,prior to its issuance.also ELEC.CONTE. LIC.NO. Eof LEC.
PERMIT TO
LL requires the applicant for such permit to file a signed statement that TOTAL
a w es w he is licensed pursuant to the provisions of the Contractors License
tzar Law(Chapter 9(commencing will,Section 70000of Division 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢ r 0 the basis for the alleged
m ge exemption,Any violution of Section 7031.5 STORIES TYPE CONSTR.
LU 3 - by any applicant for a permit subjects the applicant to a civil penalty
of not more than five burred dollars 155001.1: ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do tine work,and the structure is not
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 oI'
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 s .rTVP ooR AREA TOTAL cREACE
himself or through his own employees.provided that such improve-
memsarenotintendedoroffered for sale.If,however.the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have tine burden of proving that lie did not build or im- ILDING USE
RE
prove 1,as o of sale.). INDUSTRIAL WASTE INTERIND CON PB Other
. 30.00 ❑ ❑ ❑ ❑
❑ I,as ownernee of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:Time Contractor's LiceRw 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 fo SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under sec. ,B.drP.C.R+r this WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00
A C.D TE ACC.FILE NO.
WORK ERS'r,OM P17NSA'IION DECLARATION WATER TREATING EQUIP. 5.00
I hereby nffirm that I have a cerlificatc of consent to ,Ifainsu¢,
or a certificate of Workers'Conmp lfation Insurance,or a certified ( ZONING ENG.SITE NO.
copy themof(Sec.3500,LaUC.). % - I I f
Policy No.-- ..Qp I q y_
O ❑ CcrtlBtl 0deyeo�r FIRE SPRINK ENERGY T24
Z
z C�Certil'ied copy s I- n the city inspection division. MISC.- REFER TO ORD.0 AP cant Y ❑ IN V ❑ N❑
h CH R'IT 1'1 CATLEht P1'I(1N FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPEN ATION INSURANCE PLG.CONTE. LID.NO. PLG. ❑ ❑ ❑ O
0 This section need not be completed if the permit is for Ot TOTAL V N V N
hundred dollars IS 100)or less I
U 0 1 certify (hot in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
(y I- mi( is issued, I shall not employ any person in any loonier ser us to
.O W become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>- W N'OTIC17 TO APPLICANT: If,after making this Certificate of F.x-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you Friuli forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTR UCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10.000C.F.M.) 6.00 SEISMIC FEE7/
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name hank of America P n
Lender's Addrsss lQo__r� D. HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC '
I certify that l haveread this appSicationund%=11,7.1ove 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
above mentioned property for inspection purposes. BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino again t Iia hies,ju nen(s, costs and expenses which PERMIT ISSUANCE ' 10.00 CONST.TAX /
may in any w c le agail said City in consequence of the
granting Of chi end sig MECH.CONT. LIC.NO. MECH.
/ �- .; S TOTAL
Signature of Ap is n ontodor TOTAL
INSPECTOR COPY