10300 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
BUILDING - APPLICATION & PERMIT O 0O
ADDRESS
10200 Carmen Rd. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - PLAN CHECK VALIDATION,
NAME
Mr. & Mrs. Marek 257-3968 CITY- ' ELECTRIC PERMIT FEE
PHONE
CONTRACTORS
NAMECity Lic. .8050 UTLETS-SWITCHES-RECEP 10.00/1.00 I
A.A.A. Furnace uc,No. 346361 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'5 -
AREs PPLIANCES-RESIDENTIAL
OX74.00
2 Stone, Ave. . PnONE293-4717 ' PANELS 10.00 DATE OF APPLICATION
OR
RCHITscT - PANELS (OVER 200 AMP) 20,00 PLAN CH C_K.FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00 -
ADDRESS Ervc. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. -20.00
APPLICANT'S ' 1 - -N•Y�W
AD DRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION' TEMP.POLE 30.00 i1 �G G Q�j
au I hereby affirm that I am licensed under provisions of Chapter 9
z w ISSUANCE GATE -
n < n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
0" Professions Co Ise 20 full f IfFOL
Z O= License Class �' ��m y&l,c�'Li umber4��xagg(( &
O 2 f w Date l 7 OG Contractor 1 e -
F ; _ T. 17 86 277145
¢ z ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
- 0 W o MISC:- ' REFER'TO ORD INFORMATION
X
; N I hereby affirm that 1 am exempt from the Contractor's License
u O J Law for the following reason.(Sec.7031.5,Business and Professions - - VALUATION $/FT:
- g PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
S, ic Q 0 Improve,demolish,or repair any Structure,prior to its issuance,also ELEQ CONTR.
ELEC.
be Sl licensed es file
cnsed pursuant to the proviicant for such sion,sit to file a signed statement thatTOTAL
ion,of IleContractot e License PERMIT TO
r Z.a
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
4 D Business and Professions Code)or that he is exempt therefrom and /_D
¢ H$ the basis forthc alleged exemption.Any violation of Section003 LOTV. PLUMBING PEflMIT FEE5 STORIES TYPE CONSTR.
u ; by any applicant for a permit subjects the applicant to a civil penaltyI
ALTER-DRAIN&VENT-WATER (EA.)' 5.00 j
of not more than five hundred dollars($500).): , -. -
❑ 1,as owner of the property,or my employees with wages asBACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.uNlTS�,
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,_AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such workF IXTUR ES-PER TRAP 5.00 so.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees provided that such improve
or improvemenotnt is
oroffered
one or year
If,however,the theo nee- GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is a bur en o one ving of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of the p RES IND CON PB DUM1af
❑ I,as owner of the property;am exclusively contracting with
INDUSTRIAL WASTE INTER. 30.00 '
❑ ❑. ❑ ❑ ❑
licensed contractors to Construct the project(Sec:7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 - ASSESSORS PARCEL NO.
and Professions Code.The Contractor's o Improv Law does not apply
to tr owner of properects wi builds tr ctoms)licensed
thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with n con[mptor(s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. -PARCEL No..
❑ I am exempt under Sec.
reason BAP.C.for this WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE Acc.FILE NO.
WORKERS'COMPENSATION DECLARATION - WATER TREATING EQUIP. 5.00
1 hereby affirm tisat 1 have a certificate of consem to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec,3800,Lab.CJ.
Policy Not OmQp�' State Campeng^hi
O ❑ C Il et 41e ERy'p3
j p L ]
Z Z pe rtified c li D' led fnux# IPec[Nfr136NKion. FIRE SPRINK ENERGY T-24
i.
O Applica MISC.- .. REFER TO ORD. Y ❑ N❑ Y❑ N❑
_ CC ' CER ICATF-OF EXEMPT NFROM WORKERS' -PERMIT ISSUANCE''- 10.00 FLOOD ZONE A.L.u.c.
W COMPENSATIO NSURANCE PLG.CONTR. LIC.NOV 'PLG.
CL � . Q Y N
D Z (This section need not be completed,if the permit is for one ` TOT_- - ❑ ❑ ❑ ❑
U 0 hundreddollarsthat
the pe less:) r N fAI
I certify that in the performance of the work for which this per- �" FEE SUMMARY
DTV. MECHANICA►tP4ERl� FEE
LL 1- mit is issued,1 shall not employ any person in any manner so is to q
OUU become subject to the Workers'Cam pensulion Laws of California. BUILDING
G. Date Applicant ALTER OR ADD TO MECH. ude • , 0
} 0 NOTICE-TO APPLICANT:: If,after making this Certificate of Ex-
emption, ou should become subject to the Workers'Compensation;
H - Y IAPPLIANCE - 1 5.00 PLAN CHECK
provisions the Labor Code,you must forthwith comply with` FEE
V such provisions or this permit shall be deemed revokes, AIR HANDLING UNIT(TO 10,OODCF.M.) 4.00
;CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10AWC.F.M.) 6.00 SEISMIC FEE -
I hereby affirm that there is a construction lending agency for - EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work ton which this permit is issued(Sec. MICROFILM
3097;Civ.CJ. 1 HEATING UNIT(TO 100,000 B.T.U.1 8.00 -
Leader's Name
Lender's Address' - HEATING UNIT(OVER 100,000B.T.U.)8.50 ' ELECTRIC
1 certify that I have read this application and State that the above VENTILATION'FAN (SINGLE) 4.00
Information is corneae I agree to comply1with all city and county BOILER-COMP PLUMBING.
I ordinances and state laws relating to building construction, and (3 H.P.Or 100,000 B,T.U.) 6.00
•' hereby authorize representatives of this city to enter upon the
above-mentioned property Tor inspection purposes: BOILER-COMP(Over 100,000 BTU)$ EFEE SCH 'MECHANICAL
(We) agree to save, indemnify and keep harmless the City oL - MISC,- • EFEA TO
Cupertino against liabilities,judgments costs and expenses which PERMIT ISSUA CE lWrl CONST.TAX
n way accru :,gains City in cons quence of the
grenting of[ i9 permit MECH.CON LIC.N MECH.
r / TOTAL TOTAL VO
n of Applicant/Contractor Da ,(�
..r OFFICE COPY