6989 • -40,PP,LICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
} r,BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AuqB,ess,!
/110300 Stevens Creek Blvd. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6989
OWrveR'S PLAN CHECK VALIDATION
)NAME/,'tai PYlZBeL'tlel79 DTV. ELECTRIC PERMIT FEE
PHONE
_r
CO
OMERAcroR UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. 323090 LIGHTING FIXTURES 5.00/1.00
LONTBACTOn.O.� ,2380 APPLIANCES-RESIDENTIAL 4.00
ADDRESS
y,is
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHrtELT SIGNS S.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
u
- c.rvo. SIGNS TRANS. 3.00
ARCHE RENO. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
._ SS
ZIP EMP.METER OR POLE INS. 15.00 -
APPLICANTS P.DEB 23SO MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 %//O
ys' o o LICENSED CONTRACTORS DECLARATION
u. -I hereby affirm that I am licensed tinder provisions of Chapter 9 ISSUANCE DATE
r Yl G 1O ( e➢ ing with Seel on 7000)of Division 3 f fie Business and BLDG. ELECT. PLG. MECH.
H N i professions Code -n y license is o In
Il lbreerr)llyf t.
1. OhA - Il en'e CI'h.as L Ntnbr 4%{ - ❑. .R ❑ ❑
\.O z J w Udl 6�-2518 C mmet r - _ '.`. -V, t'.r -,Q 1
st m s BUILDING PERMIT
•¢ w at OWNER BUI LDf R DLCLAR, INFORMATION
ea MISC.- REFER TO ORD
�w 3LL r 1 hereby affirm that I um exempt from the Contractor's License VALUATION $/FT.
-FUO4 Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00.,'
Code:Any city or county which requires a penton to construct,alter,
e Q0 improve•,demoliih,or repairany structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. A
r n
u m R t luhr s.the dpph dol for such Permit 1 file a signed still ui•nl that TOTAL PERMIT TO
w
lie Is licensed pursuant to the provisions ,!'tine Contractor-License
HiQ 1 (C.hapter'J( i..Tenting with Section 7000) 1 Division 3 ofthc
i O Business and I'rullss ons Code)or that he is exempt therefrom and OTY. PLUMBING PER FEE
at I- o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
5,: by by any applicant for a permit Subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.),4.00 tY 'xr
of not more than five hundred dollars($500).): '
❑ 1,as owner of the property,or my employees with wages asa
j- (heir sole cnmpensulion,will do the work,and the structure is not BACKFLOW PROTECT. DEVICE 2.00 OCC.GROUP,,. IT uwTs
intended or o11'cred for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
;Code:The Contractor's License Law does not apply to an owner of
properly who build,or ImproVex lllcreoll,ami who,lees ilot,work FIXTURES-PER TRAP 4.00 g0,FT.FLOOR AREA TOTAL ACREAGE
himself ur through his bwn employees,provided that such improve-
mentsare not intended oroffered lir.sale.If,however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
h or improvement is told within no year of completion,tine owner- GAS-EA.SYSTEM-OVER 4 IEA.).` BUILD
builder will have the burden of proving that be Jid not build or im- BUILDING USE
prove for purpose of sale.). RES IND CON PR Ohhei
❑ I,as owner of the Riprl rc.,liuivel -rontic."in•with INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
P ist y.he y� g
licensed roion, od to construct O® project(Sec.Wdoes,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
to Profusions Code The Con buaor's License Law dyesnonapply to an owner Ol properly lwhowI huildso500111veslhcron. cant to LAWN SPRINKLERS-OVER 5IEA.) 1.00
thcC.ut ctsuch Projectswitha anhlmetods)licenser pursuant to
the Contractors License Law. ( -..;
SEWER-SANITARY-STORM EA.200f1/8.00 " , TRACT No. PARCEL No.
❑ I in esompt undur See B.&PC.tier nhls WATER HEATER W/VENT 4,00
r .un r
t, Owner i D. WATER SYSTEM 4.00 A - -s
ACC.DATE ACG FILELE NO.
WORK 1:RS'CONIPENSATION DI'CLARATION WATER TREATING EQUIP, 4.00
119_ 1 hereby affirm Ihat I have a cerlifnudc., co....t to self-insure.
Or o certificate of Workers'Compensation Insurance,or a eerlifi.1 - ZONING.,,-, '- ENG.SITE NO.
copy thereof eyrii0l ,Lab.C.).
I. p].QLnpanv- �� _ _ _...
Ou`_�E '❑ Certllied CUp3lg 'eretiy'fun1 •d 11. •.' K' - FIRE SPRINK ENERGY T-24
z Z �ICert ified i�cd tin cine rap slim division.
O Ann can CJ.�:LI'1C� . MISC.- REFER TO ORD. Y[ _ N❑ Y [D N[]
If'• y CER'rippcA'1'1i OP EXI MPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
�}. LU .COAII'I?NSAIION INSURANCE PLG,CONTR. LIC.NO. PLG. Y� NE] Y � N❑
5 e CL O GIN,section need oat be completed if the Penn it ie for one TOTAL '
,. Z Immured dollars!$100)ar less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
t LL I- mit is issued,I shall not employ any person in any manner so as no
7 O w . become subject to the Workers'Compensation Laws of California. _ BUILDING
R. a Date Applicant ALTER OR ADD'TO'MECH. 4.00
I` } W NOTICE 'I O APPLICANT: if,after making this Certificate of Ex-
r Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 h 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 10)ODOCF.M.) 3.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10D00C.EM.) 5.00 SEISMIC FEE
I hereby afl'inn that there'is a construction lending agency lot EXHAUST HOOD WITH DUCT) 2.00
the performance of the wink for which this permit is issued(Sec. MICROFILM
3097,Cie.C). r HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lenders Address ' ELECTRICS OV ,
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is,u....ct. I agree to comply with all city unit county PLUMBING
ordinances and swtc laws relating to building construction, and BOILER-CQMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby awhuriee repnsen v ol' this city to enter upon the
aboveBOILER-COMP (Over 11NL000BTU)SEE FEESCH. MECHANICAL
-mentionid proper tori pectora purposes.
(We) agree to sa inde ify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against ' biline Judgments, cons and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
mays' any way ace against said City in co equence f the
gra mg of this ECH.CONT. LIC.NO. MECH.
%10TOTAL TOTAL
oture ol'App Contract Dat
INSPECTOR COPY