5668 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
R.I L.INCBldg. - APPLICATION & PERMIT 566
AODRF.$
208 3 Stevens Creek Blvd, BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
• NAMERS 'rF' s.:' , NS. '� n' - PLAN CHECK VALIDATION
pop
J. Volkmann & AApoc. r. s .< u
CONTRACTOR'S
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
Peninsula Air Cond.L4i�;. 436343 - LIGHTING FIXTURES 5.00/1.00
ADDRESS
OR'$ 415-369-187 PPLIANCES-RESIDENTIAL 4.00
DNTRA
CiM
1690 TaC m Wa E PANELS 5.00 DATE OF APPLICATION
ARCRIiECT SIGNS 600 PLAN CHECK FEE P.O.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDREOSS.ENa SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 15.00 )
APPLICANTS
MOTORS SEE FEE SCH.
A /
SERVICE CHANGE 10.00
o 0 o LICENSED CONTRACTORS DECLARATION
¢ u I hereby affirm Chat 1 am licensed under provisions of Chapter 9 ISSUANCE[[GATE
uHai G HIcm Rn,n6n,with Section 7000)of Division 3 of The Business and BLDG. ELECT. PLG. MEC
N z Pmicssiom Code.a ase is in full force an t ❑ ❑ Elz o ,n - Liccnq( :�s� 8St1 L'ic.Numher. s},52
o w F Uum_ Convector iii"�Ce[[Intl H
,43
BUILOING PERMIT=;+^*5,v z
C' Pr OWNER-BUILDER DECLARA'f10N +fr _•,ANP.ORMATIONA.:I�iv;
wg; I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F LL o J Law far the following reason.(Sec.703 L5,tlusiness and Professions PERMIT ISSUANCE 6.00 VALUATION S/FT.
Cade:Any city or county which requiresa permit to....trod,alter.
2 ¢ ¢ o improve,demolish,or repair any Structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
- O LL requires the applicant for such permit to file•a signed Statement that TOTAL PERMIT TO
u m he is licensed pursuant to the provisions of the Conlriclor's License
Law(chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and OTT. ' PLUMBING PERMIT.}:' `FEEia �+v
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 r - ) "r'-: STORIES TYPE CONSTR.
i ; m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than live hundred dollars 65000.
I.as owner of the property.or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
R• it sole compensation,will do the work,and the structure is not
• u:ian.led or offend for are ISec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND, 4.00
Code:The Contractor's License Law does 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.
meats are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvemem is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project ISec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions 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 contractor(s)licensed pon tent to
the C.ntmctnr's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Ium exempt under Sec.-,BAP,C.for this WATER HEATER W/VENT 4.00
reuwn
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC,FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING
m'a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
V,y1V,4'f942_"„ ,b'Fremont Indemni
❑_ Certilied copy ishenby furnish the FIRE SPRINK ENERGY T]4
z Z C C'enil Zed copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ v ❑ N❑
rte CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. Y❑ N❑ Y❑ N❑
Z I fins section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less.( ,aril - ..
U O 1 certify that in the performance of the work for which this peryki (� ZMNANII'.AAAAAP@RMITf; ti ^vPH@'.b' "I"<'Y' X,F���"^'�'!"
LL F mil is isst ed.1 shall not employ any person in any manner So as to ,w
U become subject to the Workers'Compensation Laws of California
y Dec Applicant1 ALTER ORA Do TO MECH. 4.00 4. 011 BUILDING
>_ W NOTICE TO APPLICANT: IL after making this Certificate of Ex-
~ Z cn)ption,you should become subject to the Workers'Compensation APPLIANCE f- 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000QF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITI 10,=C.EM.) 5.00 SEISMIC FEE
I 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. HEATING UNIT(TO 1 ,GOD b, '
Lender's NaMICROFILM
3097. s Nam6 None e• HEATING UNIT(OVER 100,000 B.T.U.)7.50 Lender's Address ELECTRIC
certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information n correct. I agree to comply with all city ucti county BOILER H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and slate laws relating m building c.nster upon
and
hereby authorize representatives of this city es enter upon the BOILER-COMP Over 100,000BTUI SEE FEE SCH. MECHANICAL
VV
above-menli.ned property for inspection purpous,
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which 3. 0 CONST.TAX
may i any way accrue against said Cit PERMIT ISSUANCE 3.00 in consequence of the 1
gra go]tht per MECH.CONT. LIC.NO. MECH. -•�- + .•-
e / / TOTAL
- 3 14 85 7. 00 i�TOTAL��,*cry
gnature of Ap icantlContractor Ot Date
OFFICE COPY