8514 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
Il�k e? BUILDING - ELECTRICAL-PLUMBING-MECHANICAL8514
O PLAN CHECK VALIDATION
rvnmE CITY, ELECTRIC PERMIT FEE
OBAS OF CUPERTIN P1, EI _
NAME ncTofls UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. 323AR4LIGHTING FIXTURES 10.00/1.00
noo pACTD`20823 Stevens Creek1 81 APPLIANCES-RESIDENTIAL 4.00
C2C Cupertino PRONE 252_207 PANELS 10.00 I DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
PAhNELS (OVER 200 AMP) 20.00
L .No. SIGNS TRANS. 3.00
ARCH EAsE"G 18008 SKYPARK CR.#200 SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
IRVINE . CA zap EMP.METER OR POLE INS. 20.00 ��^
ASS 0823 Stevens Creek 81v MOTORS SEE FEE SCH. V
ADDRESS
C2 SERVICE CHANGE 20.00 AUG 2 0 1985
w o o,LICF'NSED CONTRACTORS DECLARATION TEMP. POLE 30.00
c o u hereby affirm that I am licensed under provisions of Chapter 9
Naw (commencing with Section 70001 of Division 3 of the Business and -BLD MECH.
m z Professions Code n 1 my license is in full fort•: tQQ jjfe��4.
Li m o License Class Lit Number 4
N r
2 �IJatc�.� Contructore
a m "
¢ ¢ w OWNER-BUILDfiR DECLARATION inc BUILDING PERMIT
'xu 3� m I hereby al firm that 1 am exempt from the Contractor's License
MISC.- REFER TO ORD INFORMATION.
w_ .. O a Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter,
¢ 0 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
wK a h he is licensed pursuant to the provisions of the Contractor's License
O
Fz > Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY_ PLUMBING PERMIT FEE
Ei o
¢ I-m the basis for tire alleged exemption.Any violation of Section 7031.5 • STORI CONSTR. v"
a „- by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($5001):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECTDEVICE 400 OCC. s.�u TS
their sole compensation,will do the work,and tire . .
e structure is not »
intended or offered for sale (Sec. 7044, liminess and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00
Code:'fhe Contractor's License Law docs not apply to an owner of
Property who builds or improves Herron,and who does such work F IXTUR ES-PER TRAP 5.00 SO. .FLOO nayn T ALAC PAGE
• himself or through his own employees,provided that such improvc-
merits are not intended or offered for sale.Il',however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 R IND CON PB Omar
O 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,BusinessLAW N'SPRINKLE RS-1 INC 5 V.B. 6.00 ASSESSORS PARGE:NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contraetoAs)licensed pursuant to n
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
f ❑ l am exempt under Sec .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner [)areWATER SYSTEM 5.00 Ace.DA Act FILE No,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby athini thin I have a certificate of consent to selGinsure.
v certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof Sec.3800,Lab C.).
Policy No�tlpg$tl_ 4h-,n- A-RTF0p..p-
Q 9 Certdied copya tete ft n.hed. city ins F-V 6U FIRE SPRINK ENERGYT44
Z Z �1 Certified copes _ Y Is fled_with the city inspection division. MISC.- REFER TO ORD. � EI
F O Applicant {3-/�-py &I REFER v N �v N
CC CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZO/1 A.L.U.C.
LL > COAIPENSATION INSURANCE PLG.CONTH. LIC.NO. PLG.
d v� N� V� NE]
1'I'his section need not be completed it the permit is for one TOTAL
::) Z hundred dollars IS 100)or less.)
L) 0 I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation laws of California.
Date Applicant BUILDING
>_ m NO'ICI;'I'O APPLICANT: If,Liter making this Certificme of lis- ALTER OR ADD TO MECH. 5.00
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK r
S provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
t CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10)CWC.F.M.) 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.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's dddrcss ELECTRIC
I certify that l 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, an' 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 100,000 BTU)SEE FEE SCH.
aboveanentioned property for inspection purposes. MECHANICAL
(We) agree to Save, indemnify and keep hunnless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 !CONOTA
ST.TAX
may in any way accrue against said City in umsequenee of the
granting ofthis permit MECH.CONT. LIC.NO. MECH. l
TOTAL;, L 3
1 gh uture u ppliwnt/Contractor a
9I
:E INSPECTOR COPY