8224APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY aeno nec-
BUI LD1 NG PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
8224
BUII,OEa
ADM 20065 Stevens Creek Blvd.
OWNER'S
NAME
Cupertino ProfesaiOnBIJECtr,
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
,r
/
CONT ACTORS
NAMEGuardian Automatic
UTLETS- SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
4r,ers, IncLIC.N
ADDRESS TRA T Rs 950 North Rengstorff - G
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
P"ON
DATE OF APPLICATION
OR"'
ENGINEER�
LIC. NO.
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE I P.C. NO,
_f
SIGNS TRANS. 3.00
ARC H. OR ENG.
ADDRESS
SPECIALCIRCUIT '5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
- ZIP
s
ADDRESS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
/�(;�/
LICENSED CON' IFRACTORSDECLARATION
TEMP. POLE 30.00
„
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division.3 of the Business and
Professions Code, mal my license is in full ft rce and effect.
License Cl' �(`e Cmil'a mbe, 20$5522_
Dole Comructor
ISSUANCE DATE
BLDG. ELECT.
�
PLG. 'MECH.
❑ 0
y
BUILDING PERMIT.
., INFORMATION
J-1uV7<u
OWNER -BUILDER DECLARATION-
I hereby affirm dict l am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and ProfessionsPERMIT
Code: Any City 'or county which requires a permit to canstruc4 alteo
improve, demolish, or repair any structure, prior t0 its issuance, also
mgfires (lie applicau Lfor such permit to fileli Signed Statemm�t that
he is licensed pursuant to the provisions of-ICIlle Contractor v License,
Law (Chapter 9(gpmanencing`*'ith Section 7000)'pt Division3 ofthe
Business and Professions Code) or that he is exempt therefrom andOTY.
---- - - --i
- - ` MISC. - REFER TO ORD - -
ISSUANCE 10.00
VALUATION
46,000
S/ET.
ELEC. CONTE. LIC. NO.
ELEC.
TOTAL
PERMIT TO
Fire Sprinklers
PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to acivil penalty
of not more than five hundred dollars (S500).)ir
ALTER -DRAIN -WATER (EA.) 5.00
❑ I, as owner of the property; or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
,' DRAINS -FLOOR, ROOF, AREA,CONO. 5.00
intended or Offered for sale (Sec. 7044, Business and Protessiois
Code: The Contractor', License Law docs not apply to an owner rel'
- F.IXTUR ES - PER TRAP 5.00 '
GAS - EA. SYSTEM - I INC.4 OUTLETS 6.00 '
properly who builds Of Improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsarenotintended oroffered for sale. If, however. the huikling
SO. FT, FLOOR AREA
TOTALACREAGE
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or ire-
prove for purpose ofsaleJ'
❑ I, as owner of the properly, am exclusively contracting with
- . -..
GAS EASYSTEM OVER 4 IEA) 200
BUILDING USE
RES .IND CON PB Orn.,
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors t0 construct the project (Sec. 7044, Business
and Professions Code: *file Contractor's License Law does non apply
to an owner of property who builds or improves Ihemon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contractors) licensed pursuant to
lite Contractor's License Law.
SEWER -SANITARY -STORM EA. 200it/10.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec.-, BAP.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
PCC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORK ERS'COMPENSA'TION DECLARATION
l hereby affirm than l have a certificate.('consent mscll-insure'
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab.C.).
Policy No. Company
❑ Cerlilicd e'opyis hereby r Mutual
❑ Certified copy is Filed with the city' inspection division.
y
%iplpllican;
FIRE SPRINK
V ❑ N❑'
ENERGY T-24
V ❑ N❑
MISC. - t REFER TO ORD.
CE R'IT 171CATIE OF I XFMPTION FROM WORKERS'
...
PERMIT ISSUANCE 10.00
PLOODZONE
A.L.U.C.
COMPENSATION INSURANCE
ot be completed it the permit is for one
section need nm
PLG. CONTE. LIC. NO.
PLG.
TOTAL
Y E] N ❑
V E] NE]
hundred dollars IS 100) or Tess.)
I certify that in the performance of the work for which this per-
fait is issued. I shall not employ any person in any manner so as to
DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
265.00
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE *1'0 APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00
PLAN CHECK
FEE
1]2.'25
eniption, you should become subject to the Workers' Coni pensat ion
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO IOMC-F.M.) 4.00
AIR HANDLING UNIT (OVER 10PWC.F.M.) 6.00
SEISMIC FEE
3.22
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec
3097, CMCJ.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
1-cuder's NAddmames
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
I certify that l [lave read this application and state tial the above
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER- COMP (3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,0008TU) SEE FEE SCE.
MECHANICAL
hereby"author" representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs cud expeaws which
may in any way accrue against said City in, consequence of the
CONST. TAX
-
PERMIT ISSUANCE 10.00
grantingofthis I,t. -n
3=18-85
MECH.CONE. LIC. NO.
-
MECH.
TOTAL
TOTAL
440.47
Signature of Applicant/Contractor .(Date
- "` INSPECTOR COPY