5738 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT jOB # D888ADDRES5738
19743 Wintergreen Drive Cupertin
)BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
O.DER'S PLAN CHECK VALIDATION
.
NAME
M/M Steven Dud1e Y ( n/a QTY. ELECTRIC PERMIT FEE
PHDNE
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
CAL-PAC ROOFING, INQNO 379503 LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00 '
144221 S. Grimmer B 1yANE 651-3371 PANELS 5.00
DATE O
ORRCHRECT SIGNS 6.00 ,1 PLAN CHECK FEE APPLICATION
PNC.NO.
Eltl-Mont, CA 94538 LIE No. SIGNS TRANS. 3.00
ADDRESS ervc. SPECIAL CIRCUIT 5.00 PE 'jAID`n�LIOATION
ZiP EMP.METER OR POLE INS. 15.00 AU 0./
ADDRESS MOTORS SEE FEE SCH. JUN
ADDRESS 1
0
SERVICE CHANGE 10.00
,00 LICENSED CONTRACTORS DECLARATION City Of CuQe(tino
v1 herehy affirm that I am licensed under provisions of Chapter 9 . ISSUANCE DATE
e z w (commencing with Section 7000)of Division 3 of the Business an() BLDG. ELECT. PLG. MECH,
D'z Professions to and my license is in full forL3n.503. ❑ ❑ E3
i, z o 0. --. .Liccn. I.i q mben ::77,,_,
Y a'< BUILDING PERMIT
F o w a (IWNISR-B UILDIiR DIiCLARATION INFM
ORATION
,X zi y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
FLLof Law for the following reason.(Sec.7031,5.R.Mnessand Professions PERMIT ISSUANCE 6.00 VALUATION S/FT.
Code:Any city orcomnty which requires a permit to construct alter, $6 550.0.
RQ improve,'demolish,or repair any structure,prior to its issuance,also ELEC.CONTE_ LIC.NO.
c, ELEC. ,
- O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m he is licmrsed pu Runnt to the provisions of the Contractor's License
FZLaw Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
Q
is Business andProfessions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
710. the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
tag _ by any applicant for a permit subjects the applicant to a civil penalty, ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).):
O I,a owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 '
Code:The Contractor's License Law dors not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC_40UTLET$ 4.00
Hours are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
1 builder will have the burden of proving that he did not build or im-
7 prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Other
/ ❑ 1,as owner of the property,am exclusively contracting with r5c ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARC ELNO-
and Professions Code:The Contractor's license Law does not apply
to an owner of property who builds or improves Wercon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmetons)licensed Panamint to
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
3 ❑ l and cxcmpt un der Sec .LAP_C+for this WATER HEATER W/VENT 4.00
Boson
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILENO.
! WORKI'.NS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm than I have a cerilic'utu of consent to scl6insure, ZONING ENG.SITE NO.
or a certiDcme of Workers Compensation Insuounce,or a certified
copy meg See l�C.k
P<,heyNdl ,f , Royal Ins. Co.
0' Cetlifled copy Is hereby furnishc - FIRE SPRINK- - ENERGY T-P4a(,
CetllHe o filed-wit i "TIS. ton division. MISC.- REFER TO ORD.
z O nnphwnt Y❑ N❑ Y ❑ N❑
y CI!R" JCA'I'Ii OP ;XEMI TION FROM WORK-RS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.LU c.
dOCOMPENSATION INSURANCE PLG.CONTR. 1 LIC.NO, TOTAL YE] N❑ v❑ NE]0 fl'his section need not be completed if the Perrot is for one
hundred dollars(S 100)or less I
L) O 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
U become subject to the Workers'ConnpensaGon Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 62.50
} N NOTICE TO APPLICANT: If,aitch making this Certificate of Ex-
F ? CHIPHOn,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U suds provisions or this permit shall be deened revoked. AIR HANDLING UNIT(TO 10p00C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10,000C.F.M.) 5.00 SEISMIC FEE . 50
1 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,C1v.C.). HEATING UNIT(TO 100,000 B.T.U.) '4.00
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that l have read this application and state that the above VENTILATION FAN ISINGLE) 3.00
information is correct.I agree to comply with all city and county PLUMBING
ondinmmes and state laws relating m building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this.ody to enter upon the
above-mentioned property for inspectionpurposes. BOILER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL
• '
(We) agree to save, indemnify,snd keep-harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gr di go xIver It. _a / 2/85 MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
•natureoff plicant/C utractor Date $63.0U
INSPECTOR COPY '