14192 (2) APPLICANT TO FILL IN IN 10 WITHIN RED LINES - USE B• POINT PEN ONLY
BY LDING PROJECT I DENTI FICA T PERMIT NUMBER
BUILDING -_ APPLICATION & PERMIT ^ A A ^n
�4 AODR2 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 14 192
21130 Rainbow Dr. Lot #1
OWNER'S PLAN CHECK VALIDATION
�A NAME QTY. ELECTRIC PERMIT FEE
The Gregory Group PIED 595-2100
caoRs
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
' Central Service Co. LIc.No. 171537 LIGHTING FIXTURES 10.00/1.00
OSOWB
CONTRACTORS
ONTRDREAS PPLIANCES-RESIDENTIAL 4.00
S
625 Charles Street PHONE 298-0556 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE D.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
zlv TEMP.METER OR POLE INS. 20.00
Avvucarvrs MOTORS SEE FEE SCH,
ADDRESS 625 Charles St, SJ 95112 !
SERVICE CHANGE 20.00 ��// 3I F-7
o o LICENSED CONTRACTORS DECLARATION
u I botchy affirm (hut I in licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
y r 4� BLDG. ELECT. PL MECH.
H o i Professions Code, d license is in full fort a(yLyire ❑
z O w License Qlryss 1 Lic.NumberEl C1
9 m Date 11 Contractor_ n Tilery Ce
er m s BUILDIN PERMIT
¢ M < OWNER-BUILDER DECLARATION
BE w u INFORMATION
X ;a.a H 1 hereby affirm it, I am exempt from the Contractor's License MISC.- REFER TO ORD
u00 Law for the following reason. 7031.5,Businessand Profess ions PERMIT ISSUANCE 10.00 VALUATION $/FT.
to Code:Any city or rounty which requires a person to consUucl,alteq
2 rt a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
6 requires the applicant for such permit to file a Signed statement that TOTAL
n w m LL he is licensed pursuant to the provisions of the Contractor's License - PERMIT TO s
r z i
Law(Chapter 9(Inmmencingwith Section 7000)of Division 3 ofthe
m o Business and Professions Code)or that he is exempt therefrom and T PLUMBING PERMIT FEE VYTI
S' H$ the basis for the alleged exemption.Any violation of Seclion 7031.5 21STORIES T PEC NSTR.
by anyapplicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 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, 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 work 12 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-11 NC.4 OUTLETS 6.00 .
or improvement is Sold within one 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 im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,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: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 pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 ---
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMP NNSATION.DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
'
or a certificate of Workers'Compensation Insurance,or u certified
copy therep�}$�y,�pJ�Q,Lab.C.).
Policy No.JS..1V�Alpany_]?aC1f1C-CQmn
O Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z O Certifie py 's Je ith lhP city in. tion division.
Applicant MISC. V- REFER TO ORD. [3N V
❑
C] E]
N
CC CERTIFICATE 017 EXEMPTION FR ORKERS' PERMIT ISSUANCE 10.00 --- FLOOD ZONE A.L.U.C.
LU COMPIiNSATION INSURANCE PLG.CONTR. LIC,NO. PLG.
CL Z (This section Good not be completed if the permit is for one Central Service 171537 TOTAL --- V❑ N❑ Y❑ No
hundred dollars(S100)Goless I
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ 1- mit is issued.I shell not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
s Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of E.-
caption,you should become subject to the Workers'Compensation 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 10A000.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=CF.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 for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name H EATING UN IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
• 1 cerlil,that l have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.Ror100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BE
(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harniless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, casts and expenses which CONST.TAX
may in un way accrue against sold City in consequence of the PERMIT ISSUANCE 10.00
gr. gof hispe til. MECH.CONT. LIC.NO. MECH.
4.1-13-87 TOTAL TOTAL
ignature Of Applicant XGIRW .Date
-Ab
OFFICE COPY