5738 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
75738
MBER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
BUILDING
"DRESS JOB i9 1 848 '
A19743 Wintergreen Drive Cupertin BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNERP CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
M/14 Steven. Dudley PHONE n/a
NAM[RAcroRs UTLETS-SWITCHES-RECEP 5.00/1.00
CAL-PAC ROOFING, INq,, NO 379503 LIGHTING FIXTURES 5.00/1.00 '
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
P442
1
S. Grimmer B1yaNP651-3371 PANELS 5.00
DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
E"Mont, CA 94538 LIC.NO, SIGNSTRANS. 3.00
APROW OR ORESS ENG. SPECIAL CIRCUIT 5.00 P ATION
ZIP rFEMP.METER OR POLE INS. .15.00 A' p
APPLICANT'S MOTORS SEE FEE SCH. JUN 2 U 1985
POOR E55
SERVICE CHANGE 10.00 City
Of
CU
,00 0 LICENSED CONTRACTORS DECLARATION 25 Pr- ra Dertino
a is 0 1 hereby a]firm that I am licensed under provisions of Chapter 9 /„'._A
H z a (commencing with Section 7000)of Division 3 of the Business and ^ 4- ISSUANCE GATE
a
y m .�d S� BLDG. ELECT. PLG. MECH.
H N z Professions Cod.,and my license is in full fors/7PJ V s.
i o - License911s�785_ LiS.yumbc_ rte_ 1A I El El
❑
w H J DafC J/__ ,fTAsVivbi`,!'t1A�F/6�fw
a m BUILDING PERMIT
ar Ix ¢ OWNER-BUILDER DECLARATION
A 0 a v INFORMATION
r 1 hereby at Arm that I am exempt from the Contractor's License MISC.- REFER TO ORD
a-o¢ Law for file following reason.(Sec.7031.5,Basincssand Professions VALUATION $/FT.
_ . g PERMIT ISSUANCE 6.00 c
m � Code:Any city or county which requires a permit to construct,alter, $6
RQ ¢ 00 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NQ ELEC. ,550.00
y u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
X as he is licensed pursuant to the provisions of the Contractor's License
r Z> Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
g i o
M r m the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to acivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(S500)J:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECTDEVICE
their mile compensation,will do the work,and the Structure is not . 2.00 OCC.GROUP RES.UNITS
intended or offered for Sale (Sec. 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 S6.77.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ideals ore not intended or offered for Sala if,however,the building GAS-EA.SVSTEM-11NC.4OUTLETS 4,00
or improvement 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-
Prove forpurpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON . pe 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. - 5.00 -ASSESSORS PARCEL NO.
and Professions Care-'I'he Contractor's License Law dues 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 contractur/s)licensed pursuant l0
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
- ❑ I am exempt raider Sec. ,B.&P.C.Para this WATER HEATER W/VENT 4.00
mason
Owner Dam WATER SYSTEM 4.00 ACC DATE ACC.FILE NO.
•s
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby allirm Ilett I have a ceNlficafo of consent toxelf-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thePr a �ygp,�a�e C.1.
PGBcy NOR,t iti� ty Royal Ins. Co.
O' 7 Certilicd copy is hereby form`
Z Z (1 Cerlilic n - 't t 'fns a Ion division. FIRE SPRINK ENERGY T94
O Applicant MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
9 CER" 'ICATIi01 iX1iM1'1'ION FROM WOR KhiRS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.O.
LLI > COMPCNSA710N INSURANcLi PLC.CONTH. LIC.NO. PLG. V❑ N❑ V E] ❑
CILZ (This sechbn need not be completed if the permit is for one TOTAL N
hundred dollars IS 100)or less.)
U O I certify(hat in the performance of the work for which this par- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
U. I- mit is issued, I shall not employ any person in lay manner so as to
0 W become suhject to the Workers'Compensation Laws of California.
IS. Date Applicant• BUILDING
} N NOTICIS 1'0 APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 4.00 b2.50
F Z emotion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions al' the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONS'['RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0=C.F.M.) 5.00 SEISMIC FEE .50
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the peTIOpnmlee of the work for which this permit Is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify Oat I have read this application and state thin the above VENTILATION,FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize rcpmsentalives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and ex pnnaes which CONST.TAX
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 3.00
gr nl' go it. / 2/�5 MECH.CONT. LIC.NO. MECH.
U TOTA` TOTAL
nutureaf plicant/Cifintracto,
r Dale $53.00
OFFICE COPY