8506 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
HU'LDING APPLICATION & PERMIT
ADDRESS
frellill / BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 11
OWNER' 441�2 PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
• RA-cg. s CUPERTINO r14 259-2077--
NAMEOUTLETS-SWITCHES-RECEP 10.00/1.00 ,
uc.No. LIGHTING FIXTURES 10.00/1.00
DOREss
r. N RAOT2308h Stevens Creek B1 APPLIANCES-RESIDENTIAL 4.00
A
y;C, CupertinoPHONE PANELS 10.00 DATE OF APPLICATION
ORc"I PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
* Ic.No. SIGNS TRANS. 3.00
ARCH OR ADDRESS ENG 18008 SKYPARK CR . #200 SPECIALCIRCUIT 5.00 PERMIT VALIDATION
eC.A OO ZIP EMP.METER OR POLE INS. 20.00 PAID,
APRLICA t,6823 Stevens Creek Blv MOTORS SEE FEE SCH. ['
ADDRESS L
SERVICE CHANGE 20.00 AUG 20 1986
woo LICENSI?U CONTRACTORS DECLARATION TEMP.POLE 30.00
a i w I hereby affirm that I am licensed under Provisions of Chapter 9 g,Et1�WITE
¢ w (commencing with Section 7000)of Division 3 of the Business and ELECT. PLG. MECH.
F D z Professions Code and my license is in full force and effect. ❑ ❑ ❑
z 0 License Class Lia Number
Z w Date Contractor
BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILUGR DECLARATION
a ¢a n v INFORMATION
X ;LL H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL o ¢ Law for the following reason.(Sec.7031.5,Business and ProfessionsVALUATION S/FT.
Code:Any city.,county whichreyuiresapermit to construct,alter, PERMIT ISSUANCE 10.00
¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. -
w- O u requires the applicant for such permit to file a signed statement that TOTAL PERMITTO
Lam m he is licensed pursuant to the provisions of the Contractor's License
T Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
E ¢ ¢ the basis for 0m alleged exemption.An
¢ r o ge p y violation ofSection 7031.5 STORTES TYPE CONSTR,
is by any applicant for a permit subjects the applicant me civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 /
of not more than five hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the svucture Is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
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 5.00 SO.FT.PtOMAREA TOTALACREAGE
himselfor through his own employees,provided that such improv.
ments are not intended or offered for sale.If,however,the building GAS EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
provefor purpose olsalr.)' INDUSTRIAL WASTE INTER. 30.00 RB IND CON PB Done,
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ -0 ❑
licensed contractors to construct life project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL-N0.
and Professions Codi,:The Contractor's License Law does not apply
n to an owner o1'property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts Tot such projects with a coNn¢tooO licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PAflCELNO.
❑ lam oxempt under Sec. ,B,h.1'.C.lin this WATER HEATER W/VENT 6.00
ICJS(ln
owner Date WATER SYSTEM 5.00 AC .DATE ACC.FILE NO.
WORK ERS'COM PENSA'I ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a cenificate of consent to self-insure.
or a certificate of Workers'Compensation insurance,or a certif icd ZONING ENG.SITE NO.
copythereof Sec.3800,Lab.C.).
Polity crtm,d fdy .p_!s_.may.y.�.,�y�
0- Certified co {iia led wiflll.{n the
Fl�l b 1 V I Y FIRE SPR INK EN ERGY T-20
Z Z Cert ifi-J ooy is filed illi the city 'nsp-fen division.
O ApPlicam ��� AC ('lint nT;_�fl-+17i- MISC.- REFER TO ORD. y [-] N y [:] NE] ,.
W CERTIFICATE 017 Cm7m PTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONf 1 A.L.U.D.
LL > COhi PENSAT'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (This section need not be completed if the permit is for one TOTAL v❑ N❑ v❑ IN[D
hundred dollars IS 100)or less.)
I. C) O I certify that in the performance of the work for which this per. (ITY. MECHANICAL PERMIT FEE FEE SUMMARY
!}
LL U becomt is e subjesued,ct toall the Work ot employ
s'Compensatioany person n Lawsnof Cal tornia anner so as to
II LU Date v Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
% } w NO'TICG TO AI'I'LICANI': If,alto making this Ccrlificate of E
emotion,you should become subject to the Worker Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C) such provisions or this permit shall be demned revoked. AIR HANDLING UNIT(TO 10)M00.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perfornnanee of the work for which this permit is issued(Sec. MICROFILM
11 3097,Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and State that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to Comply with all city and county PLUMBING
ordinances and state laws relating to building construction. and BOILER-COMM H.P.or 100,000 B.T.U.) 6.00
hereby' authorize representatives for
of this city cs enter upon me BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property forinspection pcity to.
I (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
a
against liabilities,judgments, costs and expenses which CONST.TAX Q 0
ny way arcme against said City in consequence of the PERMIT ISSUANCE 10.00
fhisermit. MECH.CONT. LIG No. MECH.
roTAL. TOTALo pp mart on ractor - Date ~'H-�^.
\ 1t
INSPECTOR COPY ,