7008 .s +
l�QPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT IDENTIFICATION - PERMIT NUMBER
BUILDING APPLICATION & PERMIT 008
ADDRESS 21271. Stevens Creek Blvd.. BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER's PLAN CHECK VALIDATION
NAME Blile Chip Cookies CITY. ELECTRIC PERMIT FEE
PHONE
crag's
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
NAME'
Y Action Fire Control LC.NO. 325155 LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
ADDRESS APPLIANCES-RESIDENTIAL 4.00
IHON415/65 -2114 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00 -
ADDREssENG. i.., SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 /,
war
FOO LICIiNSIiD CONTRACTORS DIiChARATION '
Q U v I hereby af'linn that I am licensed under provisions oIChapter 9 ISSUANCE DATE
F- rt w (cormcncing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
O Professions Code.�1RJpy�license P to full fore p 4e ❑ ❑ ❑ ❑
Z.
O F
L, M. Cm Numbe
Q z wti Dale Comroclor
<x a BUILDING PERMIT
wa OWNER-BUII.DIiRDbC1.ARAl'ION INFORMATION
oarMISC- REFER TO OR
I• m 3 u F I hereby affirm that 1 am exempt from t he Contractor's License VALUATION E/FT.
u.0 a Law for the following reason.(Sec 703 1.5,Business and Professions PERMIT ISSUANCE 6.00
'!Z Code:Anycity orcounty which requiresa permit tocomntret,alter,
.2 ¢ a O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. 1,777.50 s
- DLL reunites the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to lire provisions of the Contractors License
FZi Law(Chapter 9(cmnerencingwith Section 7000)ofDivision3ofthe FIRE 3PRIHICLHl2S
-a Business and Proesslons Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d5,: �2 by any applicant for a permit subjects theapplicant los civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of nm moa than five hundred dollars(4500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCG GROUP RES_UNITS
their sole 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:'rhe Contractor's License Law docs riot apply to an owner of
-property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 So.FT FLOOR AREA TOTAL ACREAGE
himsalf or through his own employees,pnwided that unit improve-
mar
entsenotintendedoroffered"for sale If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING uSE
Rudder will have the burden of proving that he did not build or ire- RES IND fOry PB Omer
prove.for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner DI'Ore property,ant exclusively contracting with m ❑ ❑ ❑ ❑ ❑
licunscd contractors to construct the project(Sec.7044,Rosiness LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contretor'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 contrnetmis)licensed pursuant to
the Contractors license Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCELNO.
❑ lam exempt under Sec.-.B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKI'RS'COM PENSA'r10N DECLARATION WATER TREATING EQUIP. 4.00
I horcby affirm that I have a Certificate of consent to sclGinsure, ZONING ENG.SITE NO.
or a certificate of Worker:Compensation Insurance,or a certified
copy thermf(Sec. 3800,Lab.C.).
Policy No. Company
Q Y Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
_ zZ�/ Certified p is IiIcJ wire the city inspection division. MISC.- REFER TO ORD.
O \ A pplicam.xx (,�� Y ❑ N[] Y ❑ N❑
M N CERTIFICATE OF IiXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
LLI >_ COMPENSATION INSURANCE! PLG.CONTR. LIC.NO. PLG.
CL O ('Pcompleted
his r,tiom need not he if the permit 1.s for one TOTAL v❑ N❑ Y ❑ NE]
::) Z hundred dollars IS 100)or less.)
U O 'I certify that in the performance of the work for which this per, OTY MECHANICAL PERMIT FEE FEE SUMMARY
IL I- mit is issued,I shall not employ any person in any manner so as to
U become subject to time Workers'Compensation Laws of California.
0 a Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 29.50
} run NO]ICU TO APPLICANT: IL after making this Certificate of E.
Z clnption,you shoal(]become subject to fire Worker:Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with - FEE 19.18
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the perforniance of the work for which this permit is issued(Sec. MICROFILM
3097,Cr,C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.P.50
Lender i Address ELECTRIC
I certify that I have read this application and state 11131 the above VENTILATION FAN (SINGLE) 3.00
• iNirnution is correct. I agree to comply with all city;uul county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby autimoruc representatives of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
aboveunenGoned property 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 PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of this pepnit. MECH.CONT. LIG NO. MECH.
\, &id >x_ ncd7e�_ 1?-27
TOTAL TOTAL 49.18
Signature of Applicant/Contractor 21 84
INSPECTOR COPY