8407 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
10905 No. Wolfe Road BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 8407
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
PHONE
GD "
NAME UTLETS-SWITCHES-RECEP 10.0011.00
11C.No. LIGHTING FIXTURES 10.00/1.00
ADDRESS
c-o T AD o s PPLIANCES-RESIDENTIAL 4.00
P E PANELS 10.06
ORSan tarl _371 DATE OF APPLICATION
A14.49 PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE, P.C.NO.
ENGINEER
LIc,No, SIGNS TRANS. 3.00
ARCH.
oo Ess ENG, SPECIALCIRCUIT 5.66 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
'
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ u I hereby affirm that 1 an licensed under provisions of Chapter 9 ISSUANCE DA E
rw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT- PLG. MECH.
rN i Professions Code,and my license E in full force and effect. ❑ ❑ ❑
' 0. - License Clary,-p.q��&Lie.Number
2 �z Date �' L V-.70 Contractor-����-�y-}-��j-q�,-�
¢ y s • 1 f 1 < <E� BUILDING PERMIT
¢ cr w a OWNF:R-BUILDER DECLARATION INFORMATION
w ;LL E- I hereby atl'um that I am exempt trout the Contracmr's License MISC.- REFER TO ORD VALUATION $/FT.
r w o a Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city c r county which requires a permit to construct.alter,
¢ ¢<O improve,demolish,cr repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- O u requires the applicant for such permit to file it signed slutmncut that TOTAL PERMIT TO
n an m he is licensed pursuant to lire provisions of the Contractor's License
F.zQ Law(Chapter 9(coinmeocing with Section 700(Hof Division 3 ofthe
Y D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for lire alleged exemption.Any violation of Section 7031.5 PE CONSTR.
t i3 °-' by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
Fuel more than five h unfired dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITStheir sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
( Code The Contractor's License Law does not apply to an owner of - `
Property wdui builds or improves fiction,and who does such work FIXTURES-PER TRAP 5.00 (, SG.tFT.FLDORAR_EA TOTAL ACREAGE
.
himself
are throughhisown employees, ,If.ho ever,hat the
improve- GAS-EA.SYSTEM-1 6.00
mm�ls are Bol intended or offered for sale.IL however,the budding
Or improvement iswithin one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA) 200
builder will have thea burdev of proving that he did not huilA or int- . . BUILDING USE
" prove for purpose of sale.). INDUSTRIAL WASTE INTER.' - 30.00 RES IND CON PB omen
❑ I,as owner of the property.am exclusively contracting with '❑ -❑ ❑ ❑ ❑
licensed contractors to construct fire project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professibus Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for Such projects with a contraclorls)licensed pursuant to SEWER-SANITARY-STORM EA,200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sea .134P.C.for this
WATER HEATER W/VENT 6.00
reason
i. Owner \ Uutc WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
!•, WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
Ihereby ut firm that 1 have a certificate of consent m self-insure,
or a certificate of Worker Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy lhercof(Scc 38 0,Lib.C).
Policy No. Company -�
❑' Certified copy is hareb)'furnished. FIRE$PRINK ENERGY TI4
Z Z ] Certified copy ii fled with the city inspection division.
]]�� MISC.- REFER TO ORD.
/ OSI Kllplicant Y ❑ N❑. v ❑ N❑
rn PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.LLC.
LU CER'I'IFIGONIP N!SAEM TION ION ERON1 WORKIiRS'
W > COMPIiNISATION'INSURANCE PLG.CONTR. LIC.N0. PLG.
Z 1'Phis suction need not be completed If Inc permit is for one i TOTAL V❑ N❑ Y ❑ N❑
hundred dollars IS 100)or Ios3f)
U O 1 contl'y that in Ore performance of the work for which this per- QTY •MECHANICAL PERMIT FEE FEE SUMMARY
1� LL I- mit is issued.I strait riot employ any person in any manner as to
U become subject to the Workers' ompensalion Laws of California.
O Q.W Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
VI } N NOTICE '1'0 APPLICANT I(,after making this Cetlifmato Of F.x- '
F2 enption,you should become subjet tO Om
re Workers'Copensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code,"yo�jmusf forthwith comply with FEE
U such provisions or this permit shall be eemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 110,000GEM.) 6.00 SEISMIC FEE
I hereby affirm that there rs a emus ruction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for whrct this permit is issued(Sec. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.)(A 8.00
Lender's Adde \. HEATING UNIT 100,000 B.T.U:)9;50 ELECTRIC
it Lcndcri Address '] .
I certify that l have read this application and state that theabove t}, VENTILATION FAN.(SIN G LE) 4-00 �W
information is correct. I agree to comply with all city and county ..y PLUMBING
ordinances and slate laws relating to building construction, and 8 BOILER-COMPI3 H.P.or 100,000 B.T.U.1 6.00
s hereby aulhori>e representatives of this city'to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL G�
above-menthwed property for inspect ion'purpu
(We) agree to save, indemnify and keep ....bless the City of MISC.- x$ REFER TO ORD. '
Cupertino against liabilities,judgments, costs and expenses which
I9
CONST.TAX
1 may in any way accrue against sac ' yin wriscquence of the PERMIT ISSUANCE ` 10.00 .�
grunting his pentnit. ( +;+ MECH.CONT. ! LIC.N0. MEGH.
1111!1 ' it 1 TOTAL TOTAL
1r/ / Sig m 1 an t m )�. Ui a 77
t�} 1l; - INSPECTOR COPY