8619 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
M (a BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING Jn O APPLICATION & PERMIT
ADORES Iq
LOT 14 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL8619
' Dwry R'B - PLAN CHECK VALIDATION
.. "AME DeAnza Group, A Ca Ornla OTY. ELECTRIC PERMIT FEE
• T.pd. Partnership norvE -
NOMERAcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
The Alden CO,,,,pAny LIC.No. 46964n ILIGHTING FIXTURES 10.00/1.00
croR's
ABORESS 411 Borel Ave,Ste. 410 PPLIANCES-RESIDENTIAL 4.00
ADDRES
San Metes Ca.94402-o,415/571-14111 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINE 6alderon-Nakamuraic ,00 13013712 SIGNS TRANS. 3.00
AARCH OR DDRESS ENG. 2070 Business CCI. $220 SPECIALCIRCUIT 5.00 PERMIT VALIDATION
Iryine- Ca. z,,92715 TEMP.METER OR POLE INS. 20.00
A411 Borel Ave, Ste. 410 MOTORS SEE FEE SCH.
ADDRESS
DDRE55
qan Maron- Ca. 9"02 SERVICE CHANGE 20.00
woo LICENSED CON'fRACfORS DECLARATION TEMP.POLE 30.00 0 ✓/0 �
a u u I hereby affirm that I am licensed under provisions of Chapter 9 1 ISSUANCE DATE
Hz et w (commencing with Section 7000)Of Division 3 of the Busine s and BLD ELECT. I PLG. MECH.
r D i 11raf"Mons Code,a d my license is in full force and efl'•ct. ❑ ❑ ❑
z o H - License Cla s �-Lie.Number
m F,o Dale Wt5 Contractor
a m f BUILDING PERMIT
Ix w a OWN
R-B 1111.DFR DECLARATI INFORMATION
oo " MISC.- REFER TO ORD
X
3 LL H I hereby affirm that 1 ion exempt from the Contractor s License VALUATION $/FT.
F u o J Law for the(allowing reason.(Sec.7031.5,Business and professions PERMIT ISSUANCE 10.00
Code:Any city Drearily which requires a permit to construct,alter, !S
IC ¢¢� improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NQ ELEC. b/
n w m, requires the applicant for such permit to file a signed statement that TOTAL - PERMIT TO
be is licensed pursuant to the provisions of the Contractor's License
H z < Law(Chapter 9(canmencing with Section 7000)o(Division3of the
Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
F m the basis far the alleged exemption.Any violation of Seellal1703 LS STORIES TYPE CONSTR.
La by any applicant for a permit subjects the applicant to a civil penalty
ALTER-DRAIN&VENT-WATER (EA.) 5.00 //
)final more than five hundred diilars($500).): _ /l
❑ 1,as owner of the properly,or my employees with wages its BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP
RES.U rt
their sole compensation,will do lire 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 FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that suchiPprove-
Denlsarenolintendedorofferedforsale.U.-however.the budding GAS-EA.SYSTEM.-11NC.40UTLETS 6.00
. or improvement is Told within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.1 2.00
builder will have the burden of proving that he did not build or im- UILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 R IND CON PS Omer
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construcl tiro project(Sec. 7044,Iiusiness LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and n owner of property Conbridds Iprov Law docs nil apply
to;in owner of property who huilde tr iPprovcs rased j .and who LAWN SPRINKLERS-OVER 5(EA.) 1.Q0
f
contracts Liceneclswitlw clmlmctor(s)licensed punumum SEWER-SANITARY-STORM EA.200tt/10.00
IIIC COn DactUl s License Luw, TRACT N0. PARCEL NO.
O I am exempt under See ,B.&I'.C.for this WATER HEATER W/VENT 6.00
r
OwivnerZ
Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
w'ORKERS'COMPENS\TION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to sd i'mone, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,LahC.). �+q
Policy el--ggi�gg+� h h IY Tye-Ayy�y-��.ampa� FIRESPRINK ENERGY T-24
❑ CcrldSed eef b lh I n��
Z Z ApCyCCerfified ' h the city inspection Aivisiin. MISC.- REFER TO ORD. y❑ N❑ v ❑ N❑
O_- Pin 1-1 IC 'I{{��
ir Ln CIi RTIFIC.\�.XEMPTION FROM WORK HRS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.O.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC NO. PLG.
0. 0 1'fhis section need not be completed if tE]ie permit is for one TOTAL Y N❑ Y 1:1 NEI
hundred do11ars(S100)or less.) f
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any Panner so as to
O become subject to tire Workers'Compensation Laws of California. �y
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING d✓
} N NO1TCE-TO APPLICANT''. II',after making this Certificalc of Ex-
F ? enlpl ion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code. you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
i
CONS'IRUerION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C-F.M.) 6.00 SEISMIC FEE 71
1 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. MICROFILM
3097,Civ.C.l. HEATING UNIT(70100,000 B.T.U.) 8.00
Lender's Name Rank of Amar4ca P 0HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
f
I I a •• VENTILATION FAN SINGLE 4.00
certify Ina[ have rend this.cio cion it N Ihu above (SINGLE) 8
information n correct. I agmc to cotoply with all city and county PLUMBING
oNinances and stole laws relating m building connnlelion, and BOILER-COMP(3 H.P.or 100,000 B.T.
U.1 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ahove-mentioned properly for inspection purposes.
(We) agree m save, i d nify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against In 'li a judge is, costs and experees which CONST.TAX
may in any way u a Bins[ sad City in Consequence of the PERMIT ISSUANCE 10.00
grantingoftl pen ' MECH.CONT. LIC.NO. MECH.
5l-31/ 5 TOTAL TOTAL hAs
Signature of Appli<an/' n ractor Uale
INSPECTOR COPY
I