8612 (3) - APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION -APPLICATION PERMIT NUMBER
yea," AooREss ��
8612 LOT 21 BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
i
OWNE PLAN CHECK VALIDATION
NAME DeAnza Group, A California QTY. ELECTRIC PERMIT FEE
artnerchip PHONE _
NOMERACT Rs UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS 411 Borel Ave,Ste. 410
HON _ • PANELS 10.00 DATE OF APPLICATION
RC
OR RrtECT PANELS (OVER 200 AMP) .20.00 PLAN CHECK FEE P.C.NO.
O
ENGINEER
c.No. SIGNS TRANS. 3.00
ARCH.ss ENG' SPECIAL CIRCUIT S.00 PERMIT VALIDATION
2070 Business Ctr. 0220
A2,P EMP.METER OR POLE INS. 20.00 MOTORS SEE FEE SCH. �✓
VPucANr$
AppRE55 411I Ce Borel Ava, Ste. 410
Ran Mpt-po, CA 91LA07 SERVICE CHANGE 20.00 /
woo LICENSED CON TRACTORS DECLARATION TEMP.POLE 30.00 //fj /r
J
¢ v 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(conn..lancing with Section 7000)of Division 3 of the Busine mtA BLDG ELECT. PLG. MECH.
D i Professions Code,Slid my licunse is in full furca a I efflict. F-1 ❑ ❑
z 0 License ClSss Lic.Number
0 y I-w Date ���1 g� Contractor_
_.-
a r E �; BUILDING PERMIT
¢ ¢ wOWNER-BUILDER DECLARA • INFORMATION
w 0 d I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
w VALUATION $/FT.
r a. 0 j Code:Any city or county which requires a permit to construct,alter.Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00
/2 Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- O ¢ requires the applicant for such permit to file a signed Statement that TOTAL PERMIT TO
La m he is licensed pursuant to the provisions of the Contractors License
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
s i 0
¢ moo the basis for the alleged exemption-Any violation of Section 7031.5 STORIES TYPE CONSTR.
dam by any applicant fire permit subjects tile applicant macivil penally ALTER-DRAIN -WATER (EA.) 5.00 A/
of not more than five hundred Dollars(my ): 'v
❑ I,as owner of the property,or my,andt employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.GROUP RES.UNITS
10221
Their sole coin patsatifor will(S the work,and the structure is not
intended or ontr cd for role (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not wloan owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.88 50,FT.FL R AREA TOTAL ACREAGE
mcIatsl re through his own emred for s provided that such improve-
mentsarenotintendedorolferedforsale.It7howeveq the building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
- builder will have the burden of proving that he did not build or im- UILDING USE
s,A prove forIND CON PB o
purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 REs re.
❑ I,., owner of the properly,m,exclusively conlrecling with ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 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-OV ER 5(EA.) 1.00
contracts for such projects with S contractors)licensed pofmantm SEWER-SANITARY-STORM EA.200ft 10.00
t the Contraclois License Law, / TRACT NO. PARCEL NO.
❑ 1 am exempt under See. ,B.&P.C.for this WATER HEATER W/VENT 6.00 / /1
reason LP 6
Owner Date WATER SYSTEM 5.00
ACC.DATY ACC.FILE NO.
WORK L RS'COMPEN'SATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to Self-insure. - ZONING
or a certificate of m
Workers'Copens:dion Insurance,or a certified
ENG.SITE N0.
copy lhcreof(Suc.3800,LSb.CA ��
raicy No. n �, i�81�Compan .
❑ Clartif 1 }' urn FIRE SPRINK ENERGY T 2
Z Z ❑❑yy CT1fieA copy Iu t clty Inspection divlslon.
0 ApI11tc.Inl MISC.- REFER TO ORD. v❑ N v ❑ NE]
CC y CERTIPICAT MW. E11PI'ION'PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 c.
W COMPP.NSA ION INSURANCE PLG.CONTR. LIC,NO. PLD.
(I his section need not be completed if the permit is for one TOTAL Y❑ IN F1 Y ❑ N❑
hundred dollars IS 100)or less.)
U 0 -' 1 certify that in the performance of the work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,1 shall of employ any person in any manner so as to
O ubecome subject to the Workcrs'Compensation Lows of CaliforniaED BUILDING
Q. Dale Applicant ALTER OR ADD TO MECH. 5.00 -
} to NOTICE TO APPLICANT: If,after making this Certificate of fix-
F-Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions m this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION LENDING AG17NCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE /
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.CJ: HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name Rnnk of AmerIC0 R A HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Addrass��ro��
I
Icerti(y thmlhave reed this applicwion enJ , tltla above VENTILATION FAN (SINGLE) 4.00
• information is carred. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP I3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to enter upon the BOILER-COMP IDVar 100,000 BTU)SEE FEE BC H. MECHANICAL
above-mentioned p operty for inspection purposes.
(We) agree ve indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino y ai s a lines,j ments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any a cue agsi t said City in consequence of the T"
granting of thi flit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL Ufa S d
Signafurco Ap II n ontr aor Dale
INSPECTOR COPY