18826 APPLICANT. TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY "
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING
ADDRESS - APPLICATION PER : 188 V
ADDRESS
r.-- 2 sTEVENS' CK�0I� BUILDING - ELECTRI L- BING-MECHANICAL
st
OWNER'5 (415) XLY PLAN CHECK VALIDATION
NAME "I
CONEL1.- 0t Co . aNE
h3'1"ZZI(p OTV. ELECTR PERM
NAME FEE
CONTRACTOR
NAME OUTLETS-SWIT 5- CEP I0rWN00b
IX - "
uc.iv O. LIGHTING FS 1 0 I
Alio ESS rags APPLIANCE SID A 4.00 .
PHONE PANELS 10.00 DATE OF APPLICATION i
ARCHITECT PLAN ECK FEE P.C"NO.
OR PANELS 1 R 2 MP) 20.00
ENGINEER 5f I A`1 zITA _ �D O
l� f 1, IY'r UC.NO C,algal SIGNS TR NS. 3.00 /
ARCH,OR ENG. ' I P,ER ITVALIDATION
Ali sL/4(LKSVUK .L.ANDINla SPECIAL CIRCUIT 5.00ly�d
it EMP.METER OR POL 20.00
A _ES FIA-NICI #'fZ5 MOTORS EE FEE SCH.
ADDDRESSDRESS
off ^I-A9?C&PU(Z .Lf2 SERVICE CHANGE 20.00 -�
w¢0 20 LICENSED CON'T'RACTORS DECLARATION
a i w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a a (commencing with Section 7000)of Division 3.1 the Business and BLDG. ELECT. I PLG. MECH. r
F y i Professions Code,and my license is In full force and stfect.
z o w- License Class Lic.Number El El
o w r w Date Coniroc(or
a x f BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
A o d O INFORMATION
w ; F I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
Foo J Law for the following rrlson.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
w Code:Any city orcounty which requires a permit to construct, 0 -
¢ Q Q 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. TE ETC D
c m m u requires the applicant for such permit to file a signed statement that TOTAL ssr� }-Kt�
he is licensed pursuant to the provisions of the Contractor's License PER
i".,i fT
FzLaw(Clmmmn
ptar9(coccingwitlh Sectinn7000)ofi)ivision3ofthc
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE W "
fE o
¢ F the basis for the alleged exemption.Any violation of$ccliun 703
malty STORIES TYPE CONSTR.
by any applicant fora permit dollar,(heapplicam macivil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than Five hundred dollars($500)J:
I ❑ I,as owner of the property,of my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.urv1Ts
their sole compensation,will do the work,and the structure is not
intended or offered for sole (Sec. 7044. Business.,,it Professions DRAINS-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 wine does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve'
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within lie year of completion, the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or inn- BUILDING USE
1 prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON' PB Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'I l e 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 contruclons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ Ianncxcmptundcr SCC. ,B.&P.C.forthis WATER HEATER W/VENT r '6.00
reason
Owner Dutc WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORK ERS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP.. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified - ZONING ENG.SITE N0;
copy thereof(See.3800,Lab.C).
Policy No. 'Company -
0 ❑ Certified Copy is hereby furnished, t FIRE SPRINK ENERGY T 24
Z Z• ❑ Certified Copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ No Y [:] N❑
p: rn PERMIT ISSUANCE 10.00
LU CIiR'I'IEICCOMP F I ATIOT'INS FROM WORKIiRS' FLOOD ZONE q.L.u.L.
LLL J COMPIi be completed
INSURANCE - PLG.CONTR. LIC.NO.-
CL
O. PLG. Y❑ N❑ Y ❑ N❑
Z (This dollars need nut be completed If the permit is for one TOTAL
hundred dollars(8100)orlCss.) - -
t U O 1 certify that in one performance of the work lot which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any Rnanner so as ie'
Ow become subject to the Workers'Compem:dion Laws of California.
Dare Applicant ALTER OR ADD TO MECH. 5.00 BUILDING22
} y NOTICE'I'0 APPLICANT: If,after making this Cerlificstc of nix-
. F. Z emption,you should become subject to the Workers'Compensalion APPLIANCE 5.00 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 10,000CF.M.) 4.00
CONSTRUCI'IONLENDING AGENCY AIR HANDLING UNIT(OVER IOAOOC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that acre is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the
crimCivi ince of line work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Leader's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
Peertify slot 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree ie'Comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER;COMP(3 H.P.or 100,000 B.T.U.) 600
hereby autmrize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly lot inspection purposes. -
(Wc) agree m save, Indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way rue against said City in consequence of the PERMIT ISSUANCE 10.00
onto, resp - MECH.CONT. LIC.NO. MECH.
. " TOTAL TOTAL
Sgn eofA plicant/Contractor. Date
OFFICE COPY