8510 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
'( BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
'I BUILDING APPLICATION & PERMIT
ADOREss
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 8510
Ow 5 PLAN CHECK VALIDATION
' NAME QTY. ELECTRIC PERMIT FEE
• AS OF CONTRACTORS CUPERTINO 14 252-2077J �
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
s Homes , Inc . D.NO. 323864 LIGHTING FIXTURES 10.00/1.00
ADDRESS 23 RESS DR208Stevens Creek. B1 d . PPLIANCES-RESIDENTIAL 4.00
CON
Cupertino PHONE 252-207 F PANELS 10.00 DATE OF APPLICATION
o3,e CT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NOdMEK .
* OE IO.ND. C009175 SIGNS TRANS. 3.00
ARCH.OR EN PERMIT VA TION
ADOREss `Y8008 SKYPARK CR. ;g(20p SPECIAL CIRCUIT 5.00
MINE, CA "P '1571 EMP. METER OR POLE INS. 20.00 AUG 20 1985
t APPLICANTS - MOTORS SEE FEE SCH.
ADDRESa 20823 Stevens Crk BI vd .
SERVICE CHANGE 20.00 City of Cupertino
R IFoo LICENSER CON'I'RACTORS DECLARATION TEMP.POLE 30.00
a v I hereby affirm IInt I am licensed under provisions of Chapter 9 f^ ISSUANCE DATE
I y¢ wd (commencing with Section 7000)of Division 3 of file Business and BLDG ELECT PLG MECH.
r• y z Professions Cod',and my license Is in full force and effect
o z m License a Lic.Nlwber�'-t2� El El 1 I1
m r Date - Contrac[or�a
a Q w a
OWNER-BUILDER DECLARATION BUILDING PERMIT
o a " INFORMATION
X g u y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F uoa Law for the following reason.(Sec.7031.5.Bisincssend Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
� w i e Code:Any city orcoumy which requires a permit loe nstruct,alter,
ca 2 <0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 u requires the applicant for such permit to file a signed statement that TOTAL
u w, he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
La as [law(Chapter 9(commencing will,Section 7000)of Division 3 of the
f 4 0 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r m the basis for the alleged exemption.Any violation of Section 7031.5 STORI TYPE CONSTR.
)t. 3 _ by any applicant to,a permit subjects the applicant to a civil penalty ALTER-DRAIN 5.00
re /
I of not mothan 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.urvlts
1 their,sole compensation,will do the work,and the structure Is not
intended or Offered for sale (Sec. 7044, Business and Professions DRAIN$-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or in)voves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.F .FLOOR AREA for LACREAGE
• himself re through his own leered for s provided that r,t h improve lding .
,i;nprovemenotnn tended or within tune yeaalc.If,howeveq l the o nee- GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement Is sold within one year of lie did
t the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
prover will have tire burden of proving that he dill not build or int- BUILDING USE
prove for purpose of theJ. RE IND CON PB'/ Omer
,I - � INDUSTRIAL WASTE INTER. 30.00 1
❑ d as owner of the property,he exclusively,1044cling withEl El D
'I 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 who
bildsContractor's License Law Joos not apply
to tr owner for
of hpropertyprojects
who ba co or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
commas ct such Lice
s with a conlmctorl sl IicenuJ pursuant to
j
fire
Contractor's Li cense Law. SEWER-SANITARY-STORM EA,200ft/10.00 TRACT No, PARCEL No. 11
❑ lam exempt muicr Sec. ,B.&I'.C.for this WATER HEATER W/VENT 6.00
reason t.
Owner DBIe WATER SYSTEM 5.00 kCt.DATVACC.FILE No.
WORK ERS'COMVI:NSATION DECLARATION WATER TREATING EQUIP. 5.00
hereby affirm that 1 have a certificate ofconsent to self-insure. �-
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereaf(Sec.38GO,LL�aDCJ. F�
Policy No. 6711 FdLfE er4_7_' .S1-HARTMORD -
U Cert;fie I m rE FIRE SPRINK ENERGY T 24
z Z Ceuifl Y ed w I t c'Y. msrection division.
O Applicant" L- C.�Ib„�`oi�r.(a__I_il MISC.- REFER TO ORD. Y N Y ❑ NC]
CC rn CER TIIICA]Ii OP IiREMP'I'ION PROM WORKIiRS' PERMIT ISSUANCE :10.00 FLOOD zONE A.L.u.c.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need Bol be completed if the permit is for one TOTAL Y❑ N iY❑ NE)
::) Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
EL H mit is issued.I shall not employ any person in any manner so as to
O O become subject to Lite Workers'Compensation Laws of California.
ED
Dam A am BUILDING
O_ NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most 1'orthwilh comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER l0,000O6M.) 6.00 SEISMIC FEE 3�
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. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
tI certify that I have read this application and scute that the above VENTILATION FAN ISINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building comtnmtito, and BOILER-COMM H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city DI enter upon file BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
j Cupertino against liabilities,judgments, costs and expse
ens which /
( I may in any way accrue against said City in consequence of.the PERMIT ISSUANCE 10.00 CONST.TAX
�( granting of this permit. MECH.CONT. LIC.NO. MECH. LLL'LLL
TOTAL TOTAL
}3 .4 dureo •n ontmetor at
e f' INSPECTOR COPY