6164 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT[FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS fV ,
21 "D'' Steven ie BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 6164
OWNER'S PLAN CHECK VALIDATION
NAkenneth Gilbeau &• QTY. ELECTRIC PERMIT FEE ONE
c.jWpXW Rulberg NAUTLETS-SWITCHES-RECEP 5.00/1,00
ME
W.L. Hickey $On8 InmD, 95122 LIGHTING FIXTURES 5.00/1.00
corvTRAc7oR's APPLIANCES-RESIDENTIAL 4.00
AD
kll Box 61209 PANELS S.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO SIGNS TRANS. 3.00
ADDRESS ENG. a SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTs
Box 61209 MOTORS SEE FEE SCH. J
AO IE
SERVICE CHANGE 10.00
Sunnyvale, CA 940880¢i
00 LICENSED CON'I'RACfORS DECLARATION O/(�
¢v U I herchy affirm (hat I am licensed mods,provisions of Chapler 9 ISS ANCE DATE
v~i i m (commencing with Section 7000)of Division 3 of the lousiness and BLDG. ELECT. PLG, MECH.
F N z Yrolessions Cod• n my license is in full tone lid effe<I. ❑ ❑ ❑ ❑
Z o — Li<enssj'la �p}bl���Lic.Numbci N$
q m°u Dulc_] —j$� Contract,
a y BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARA'T'ION INFORMATION
wDaD MISC.— REFER TO ORD
IL w I berehy affirm that I am exempt from the Coal rac tor,License VALUATION E/FT.
r LL o a law for the following reason.(Sec.703 1.5,Husinessand Professions PERMIT ISSUANCE 6-00
Code:Any city or county which requires permit loconstoreL alto, ELEC.CONTR. LIG NO.
¢ rt a 0 hnprove,demolish,or repair any structure,prior to its issuance,also ELEC.
O e, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m¢ he is licensed pursuant to the provisions of the Contraalor•s License Pig
FZQ
Law(Chapter 9(commencing with Section 7000)of Division 3 of0ue
4 0 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ I-o the basis for Tho alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant tar a permit subjects the applicant fort civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of,of more Than five hundred dollars(S5001J:
O I,as owner of the property,.r my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 DCC.GROUP RES.UNITS
their sale 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
Code:The Contractor's License Law does not apply to an owner of
properly whir builds or improves thereon,and who does such work . FIXTURES-PER TRAP 4.QQ (f18/ SO.FT FLOOR AREA TOTALAGREAGE
al
• himself through his own employees,provided(hat such im Prove _..
mors arere not intended or offered for sale.If,however,the budding n GAS-EA.SYSTEM-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.f p.viOg Her he did not build or m- \ I
prove for purposecf NdeJ. IND CON PB ' Owner
LI 1,as owner &The pa)pc ly,am exclusively contracting with INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
licensed croomelors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:"the Contractor's License Law docs nut apply
m an owner,of property who builds or improves there..,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for suchprojectsLa w.with a contortions)licensed pursuant to
the Contractor's Licencense LSEWER-SANITARY-STORM EA.200ft/B.00 TRACT NO. PARCEL NO.
D I an,exempt under Sae. ,B.&P.C.for this WATER HEATER W/VENT '4.00
rcas oI
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE No._
WORK ERS'COMPIiNSATION DECLARATION WATER TREATING EQUIP. 4.00 i
I hereby affirm that 1-have a certificate of-consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy they s{q 7y�F C.L
policy No. rh7 ry -
O 0 Cert dl is henby�nla'eC�s— � FIRE SPRINK ENERGY T-24
Z Z Jd Cvified copy is fivlernd with Die city inspection drXAA. MISC.- REFER TO ORD.
Q nl'pbcanl.Wi.L —H1=.. 90Id8�71"' El IN El ❑ N❑
a CC In C FR'I'I FICA'I'E OF Ii XEMPTION FROM WORKERS' PERMIT ISSUANCE a 6.00 FLOOD ZONE
LJ > COAIPBNSAT'ION INSURANCE PLG.CONTE. LIC.No. PLG. v❑ NE] v❑ N❑
IL o (Phis smGon need not be completed if the permit is for one .L.Hicke Sons Inc 9 122 TOTAL
Z) Z hooded dollars(8100)or IcP,)
V O 1 certify that in the performance of De work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, I shall not employ any person in any manner so as to
U become subject to the Workeri Compensation Laws of California.
ED Dam Applicrtm ALTER OR ADD TO MECH. 4.00 BUILDING
} to NOTICE TO AlIPLICAN'T: If,after making this Certificate of Ex- ^
F_ Z H,dion,you should hecwne sobjcct to the Wo,keo'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions m this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=17-F.M.) 3.00
CONSTRUCTION LENDING AGENCY - AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby affinn (hat Ihere is construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the Perrormance 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-SAM t��N�0 Bank of Califs j HEATI NG UNIT(OV ER 100,000 B.T.U.17.50
Lender's Address-q7-q—N— ELECTRIC
ccrUfy that I ITaac�caS'0lis app lea ue,3nd sf8tn01a�IQi aBGovcJ!BOILER-COMP
VENTILATION FAN (SINGLE) 3.00
infornmfion is correct. I agree to comply with u11 city unit county PLUMBING
onlinunses and stale laws relating to building <oretrugion, andOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 �d ...�
hereby authoriec representatives of this city to enter upon ohs (Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purpous.
(We) agree to save, indemify and keep harmless the City ofMISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE3.00 CONST.TAX
may in any way accrue against said City in consequence of the
gmnliog ofthiS permit. MECH.CONT. LIC.NO. MECH.
i.L. 3-3-8 5 TOTAL TOTAL
Sig,ame. I/C a Dat —
INSPECTOR COPY