6509 (5) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ABUILDINGDDRESS AAPPLICATION & PERMIT 6509
A20045 Stevane Creek BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
DINNER Frederick Petri Geor a PLAN CHECK VALIDATION
NAME , $ QTY. ELECTRIC PERMIT FEE
. Somps, Frank Bilbao .o(415)948-781
CONTRACTORS
NAME ,J L�L.7� OUTLETS-SWITCHES-RECEP 5.00/1.00
/
BWIfr UC.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S
ADDRESS /,�03 L.iGK A✓aLA J-117 APPLIANCES-RESIDENTIAL 4.00
44.1 E PANELS 5.00 DATE OF APPLICATION
ARRCHITECT S SIGNS a 6.00 I PLAN CEIECK FEE P.C.NO,
O
ENGINEER
Ray Rooker LIC.NO. SIGNS TRANS. 3.00
AR. ErvG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
sa
ZIP TEMP.METER OR POLE INS. 15.00
ADo ELS MOTORS SEE FEE SCH.
AGpR 1303 Lick Ave..
Sprig Electric SERVICE CHANGE 10.00
'o o LICENSED CONTRACTORS DECLARATION 74
aU v I hereby affirm chat I ant licensed under provisions of Chapter 9 ISSUANCE GAL
v,rt w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
R m z I'rofeaimhs CgWle,yyuudd my license is in full fuggyy...�hhppdaJjµL ❑ ❑
z o H - L icensc Class Lie.Lie.Nnmber_Nai LD ❑
o z r Date o
`a Y "CY&ig3 �
- BUILEkING PERMIT
Iz rt w u OWNER-RUILDRR DECLARATION INFORMATION
doe MISC.- REFER TO ORD
w SI w I hereby affirm chat I am exempt from the Contractor's License VALUATION
Ru04 Law for the following reason.(Sec'703 I.S.Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requirese permit to constn¢t,alter,
w ELEC.CONTE. .LIC.NU.
C improve,denwlieh,or repair any structure,prior to its issuance,also ELEC.
rii
0 u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
F
se he is licensed Purshmnt to the provisions of the Contractor's License -
F zLaw(Chapter 9(commencing with Section 7000)of Division 3 ofthe ' ��(>�-
e Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ FO tBt,basisforlhe:dlegedexenption,Any violation uf$ect ion 7031.5 STORIES TYPE CONSTR.
n g byhanyaAplicant for is permit subjects the applicant to a civil penalty
ofeet m WTtum five hundred dollars(45001.): ALTER-DRAIN -WATER (EA.) 4.00
❑ I,as owner of the property,or my unhployees with wages as BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their Sale compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
Property who builds ser improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SG.FT.FLOOR AREA TOTAL ACREAGE
himscll:or through his own employees.Provided that such improve-
mentsarenotintendedorofferedforsale.If,however.the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner- GAS-EASYSTEM-OVER 4 (EA.) 100 BUILDING USE
builder will have the burden of proving that he did not build or im . . .
- RES IND CON PB Omer
prove for purpose ofvle.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
( licensed contractors to construct Lite project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:1'1be Contractor's License Law docs not apply
to an Owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
The Comracmr's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under See.-,BAP.C.for this WATER HEATER W/VENT 4.00
mason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby allion Ilb t 1 have a certificate of consent W self-insure, ZONING ENG.SITE NO.
or ay,cIe�1r�tifficioGcaautte5�o�f��W$orkers'Compensation Insurance,or a certified
lop I�q.c.1.
!s I'nli d copy iponY-Cj,�,atiC(1y; 61�ra$e
r Z ❑ Certified copy iso by tarnished. FIRE SPRINK ENERGY T24
F( z Z �] Certifi•d curry s filed with Imt city inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
O
Alli
r V N V N
~ rn PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
lr CIi R'1'119CA'f F:,OP IiXEMI'1'ION FRQ I YORKERS'
W CGk1PEiNSATION INSURAw' C PLG.CONTR. LIC.NO. PLG. V❑ N❑ Y [:] N❑
O (This section need not be completed if the permit is one TOTAL
CL
::) Z humdre l dollars IS 100)or less.)
U O 1 certify That in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
U become subject to ere Workers'Compensation Laws of California.
0 Lu Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} to NOTICI7 TO'APPLICAN'I': If,after nm king this Certificate of Ex -
Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most I.tlhwilll comply with FEE
U such provisiunsor this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SMC.F.M.) 3.00
CONSTRUC'I'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.F.M.) 5.00 SEISMIC FEE
I hereby"affirm that there is a Construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance,of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
LenderiNdme16� HEATING UNIT(O VER 100,000 B.T.U.P.50 ELECTRIC
Lender's Address
I certify tlfm 1 have read this application and zlate that dna above VENTILATION FAN (SINGLE) 3.00 61.00
. information is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.of 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,0008TU1 SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way'accre against said City in consequence of the PERMIT ISSUANCE 3.00
granti0g of . .permit. MECH.CONT. LIC.NO. MECH.
d _ rrl TOTAL TOTA L
Sighatumof App,, ait/Contract Date" 1
l-/ V INSPECTOR COPY