5725 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDIssCupertino City .Center4Tnant APPLICATION & PERMIT771I//��rhrh20300 SteVena Creek Blvd. ILDING-ELECTRICAL-PLUMBING-MECHANICAL 0311377 -51'-25OWNER'S PLAN.CHECK VALIDATION -
NAME Y. ELECTRIC PERMIT FEE
Cupertino Ceity Crater Ae
CONTRACTOR
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
N1
ORVIN ENGINEERINGLIG.ND. 150751 LIGHTING FIXTURES 5.00/1.00
CONTRACTORS remont PPLIANCES-RESIDENTIAL 4.00
ADDRESS
4077 Peetana P1. kU/651-177 PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6.00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ARCH,08 ENG' SPECIAL CIRC 5.00ADDRPERMIT VALIDATION
ZIP TEMP.MEyffA OR POLEaINS. 15.00 �'1(iJ Q0
ADDRESS
r \�Itl//�/J
ADDRESS MOTOR SEE-FjE SCH. //
SERVICE CHANGE 10.00 f�
o o LICENSED CONT RACfORS DE:CLARA'I'ION A
¢ v u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
v~i< , (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
F w z Professions Code a it y Ifcanse is in full force and effect.
o i w W Lieens• lays 1' .\ M1e
Date�Fan� It3eh �� ❑ O ❑ . ❑
a rBUILDING PERMIT
W
it w ¢ ONER-BUILDER DECLARATION
INFORMATION
aoa MISC.- REFER TO ORD
g I herby affirm ilial I exempt from the Contractor's
na License
LL O j Law for the following reason.(Sec.703 L5,Business and Professions PERMIT ISSUANCE 6.00 VALUATION $/FT.
Code:Any city or county which requiresa permit reconstruct,alter,
¢ ¢ p improve,dmnolisb,or repair any Structure,prior to its issuance,also ELEC.CONTE. LIG NO. ELEC. 17 14 Z 0 Q
o ¢ requires the applicant for such permit to file a signed statement than TOTAL ^PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License /4'7U0/
H z rt Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe p
4 O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE '' h 'V
R/ KL
¢ f p the basis for(lie alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
p';m by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 4,00
of not more than Ove hundred dollars(S500f):
❑ I,as owner of the Property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2-00 OCG GROUP RES.UNITS
their wle Compensation,will do the work,and the structure is not
intended or offered for sale(Sec 7044, Business and Prel'essiuns DRAINS-FLOOR,ROOF,AR EA,COND. 4-00
Code:The Contractor's License Law does not apply to an owner of
property who hullds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 Sa.FT FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve- GAS 4.00
.cuts are not intended o odcred for sale.If,however,the building "If
x� or improvement is sold within one year of completion,the owner
.
.
.GAS-EASYSTEM-OVER 4 IEA) 100 BUILDING USE
builder will have the burden of proving that he did not build or int, r
prove for propose.1 sale.l. INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Other
❑ I,as owner it tire property,ant exclusively contracting with ❑ ❑ ❑ ❑ /❑
licensed contractors m construct lire project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cade:'1'he Contractors License Law does not apply /
to un owner of property who builds of improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractnr(o licensed porsount hi
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO,
a❑ lam exempt under Sec. ,8.61'.C.Ger this WATER HEATER W/VENT 4.00 /i
Owner (late WATER SYSTEM 4.00 ACC.DATE ACC.FILE 140.
WORKFRSf(OMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00 I
I hereby uflirm Ret 1 huvc a cerlificale of consent to sell-insu ru. ZONING
or a certificate of Workers Compensation Insurance,or a curlificd ENG.SITE NO.
copy ther
PolicyNrN ( 4O0,6frC �'h1A J A a.i1 ,A-
0 ❑ "•r'
e
Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
] rlific file idwy y {y m division.
Z p Apph'annnt btYp'IN btlV A'tk'Yl�tli M-IS C.r REFER TO ORD, Y ❑ N❑ Y ❑ N❑
Cr N CERT I PICA'f E.Olr EXEMPHON FRONT WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > CO1 PFNSA'1'ION INSURANCE: PLG.CONTE. LIC.NO. PLG. Y❑ NE] v ❑ N❑
Z (P[ies section teed not be completed if the Permit is for one TOTAL
hundred dollars IS I00)or less.)
U O 1 certify that in The pc,.,man,c Uf Te work for which Ihis per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- nn it is issued, I 0hx11 nal ennploy any Person in any manners,a lu
U become subject to the Workers'Compensation Laws of California.
raa Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 128.50
} To NOTICE:TO APPLICANT: It,after making This Certificam of Ex-
F Z emotion,you should become subject to lire Workers'Compensuliun APPLIANCE 4.00 PLAN CHECK
provisions of lire tabor Code, you nest forthwilh comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONS'IRUCfION LENDING AGENCY AIR HANDLING UNIT[OVER 10=C.F.M.) 5.00 SEISMIC FEE
1 Ymrcby affirm that there is a CUMAOICtion lending agency for EXHAUST HOOD(WITH DUCT) 2.00
x the Performance of)he work for which this permit is issued(Sec. MICROFILM
3097;Civ.C.) HEATING UNIT(TO 100,000 B.T.U.) 4.00
r Lende,sNm,;eBank of Amnrira NTtce
( - S`' tt HEATINGU NIT(OVER 100,000 B.T.U.17.50 ELECTRIC
1
Leader', y On AVB -�-Pa1e
1 certify than I have read this application and state That the above VENTILATION AN
(SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale law elating to build' g construction, and BOILER-COIVIP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby au Ihorizif re enlafves of th' to enter upon the BOILER-COMP lower 100,000BTU)SEE FEESCH. MECHANICAL
;1in
e-menti eJ p crty for inspecli r oses. _
Ve) rcemave, indemnify a e harmless lire City of MISC.- REFER TO ORD.
no against allies,judgme is is and expenses which CONST.TAX
nyy ace against t consequence of the PERMIT ISSUANCE 3.00 t moil. MECH.CONT. LIC.NO. MECH.
1/15/8 TOTAL TOTAL
e6&al,1.i " tractoA ea Malta er 213 . 29
INSPECTOR COPY