6505 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
BUPERMIT NUMBERILDING PROJECT
BUAPPLICATION & PERMIT
ILDING
aDDRE55
BUILDING—EL•tECTRICAL—PLUMBING—MECHANICAL 6505
Mere Steve"s 901 PLAN CHECK VALIDATION
NAME Frederick Petri, George QTY. ELECTRIC PERMIT FEE
. ON
NOME ac OHs UTLETS-SWITCHES-RECEP 5.00/1.00
4uiLIGHTING FIXTURES 5.00/1.00
no cess To s LIC ND. PPLIANCES-RESIDENTIAL 4.00 •
1303 Lick Ave, S.J. PH PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.N0,
OR
ENGINEER
Ray
Lie.-o SIGNS TRANS. 3.00 Rooker
ADDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
t" TEMP.METER OR POLE INS. 15.00
APPI.ICADDRESS rs MOTORS SEE FEE SCH.
ADDRESS .,I....J
SERVICE CHANGE 10-00
o o LICENSED CONTRACTORS DECLARATION -7/a
2 v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
wz "' (commencing with Section 7000)of Division 3 of the Business and
a n 6 ELECT. I PLG. MECH.
Professions Code..and m license is in full force and effect. I
z o I License Class _ Lic.Number 6'7x28 / El
S'O ve F O Dale— Contractor
BUILDING PERMIT
a- ¢ ¢ OWNER-BUILDER DECLARATION
a ¢o d" MISC.— - REFER TO ORD INFORMATION
w ; H I hereby affirm that I.am exempt from the Contractor's License
LL o a' Law for the following reason.(Sec.7031.5,Businessand ProfessionspERM1T ISSUANCE 6.00 VALUATION BjFT.
Code:Any city or county which requiresa permit(ocunsl...Latter,
IF Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC .
.CONTR, LIC. . ELEGNO
so K ¢ requires the applicant for such permit it)Idea signed statement that tri EC PERMITTO
e- w es u he'is licensed pursuant to the provisions of Ihu Contractor's License '
FZQLaw(Chepwr9(commencing with Section 7000)mDivkloR3althe
4 o Buseand Professions Code)or that be is exempt therefrom and DTV. PLUMBING PERMIT
ins FEE
.0 I IS H m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n by any applicant fora permit subjects the applicant Lou civil penally ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
1; U I,as owner of the property,or my.employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their cele 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- 4-00
s.. Code:"I'he Contractor i License Law does not apply to an owner of
' pntpertyiwho builds or improves thereon,and who does such work FIXTURES-PER TRAP 4-00 SG.FT.FLOORAREA TOTALACREAGE
. - h=1r or through his own employees,provided that such improve-
memsarc notintended oroDeredfor sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4-00
r impro'vemem is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
ry budder will have the bund.,of proving Hurt lie ie did not build or n- RES IND CON PB Other
- If prove forpurpou ofsale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,ant exclusively contracting with
licensed cimlracturs to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Prol'us'sions Code:The Contractor's License Law does not apply
'll to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
fire Contractor's
such projects with a contrumorl sl licensed pursuant to SEWER-SANITARY-STORM EA?200ft/8.00 TRACT NO. PARCEL NO.
the 1 it,exempt
De ere Law.
❑ lam exemprunder See ,B.&P.C.for this
reason WATER HEATER ANENT 4.00
. j li
Owner /H Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
( s
II� WORKERS'COMPI:NSA'1'ION DECLARATION WATER TREATING EQUIP. 4-00 '
1FiIhereby OR,. that I have
or a c.rsilicale of ran nt to self insurr. ZONING
I a certificate of Workers'Compensation Insurance,ora certified ENG.SITE NO.
cu pyyrrl1JJ}}yyyy,qq�� yyss}}AAgqO,L' (,'. 3
Pollcpl?kC6h� 3 of at -
0 - Cl Certified co py,is l furnish. FIRE SPR INK ENERGY TQ4
'zlZ y�t Cad it - cit inspection division.
y, 'O A111711ice' i MISC.- REFER TO ORD. Y 0 N Y ❑ N❑
~ a ` PERMIT ISSUANCE 6-00 sono zorvE A.L.u.c.
CFRTf z T OF :XEMP'1'ION P ORKERS'
LU ? '1 1 I'CO 1P. SA ION INSUR6t Ii PLG.CONTR. LIC.NO. PLG. ❑ ❑ ❑ ❑
n :) 11 This ....... need not be complete) it the permit is for one TOTAL Y N Y N
d Z li'mul cd doflarsl(5100)or less.)
U O 1 certify,thallin the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
I UL F riot is issued,I Sita]]not employ any person in any manner so as to
limnnu 1Dliject to the Workers'Compensation Laws of California.
Iia" %x Applicant BUILDING
t
V a Pn ALTER OR ADD TO MECH. 4.00
I } m Nb1TCli TO APPLICANT: IL alter making this Cert,ficat.of Ex-
F Z erignion,you slrould become subject to the WorkersCompensation APPLIANCE 4.00 PLAN CHECK
jnovisions of the,Labor Cade, You hom littlhwith comply with FEE
\V rJuch provixionx ar this p,nnit shall be dc.med ruvokad. AIR HANDLING UNIT ITO 10=C.F.M.) 3.00
CONSTRyUCrION LENDING AGENCY AIR HANDLING UNIT(OVER IODOOQEM.) 5.00 SEISMIC FEE
ll hereby infirm 01a('there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
4ic perfurmance of tire`work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name Bai�k of America
LcrWcr's Address1014ark CeUter—Plaza—a-. HEATING UNIT IOV ER 100,000 B.T.U.17.50 ELECTRIC
ill certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 ,
.50
e rfnl'nrmalion is correct. 1'agree.to consply with all city and county PLUMBING
'urdinunce� and same laws relating to building construction, and �; BOILER-COMp(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorire ropertyf.iW of this city to enter upon the '+ BOI LER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
propresylormsp of this
purposes. 'Y
/(We)/,agree to save, indenipifyx and keep harmless the City of MISC.- REFER TO ORD.
Cupertino ug:' sl liabilities,jud,ments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
/ may in,'any w y accnm dgaitist said Cily in conscyucnce of sh.
grand IS of s crmiL �I MECH.CONT. LIG NO. MECH.
OTAL TOTAL
f Sigt azure p"ant/ outmctl3e Date
INSPECTOR COPY
P 11