4708 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION FICATION PERMIT NUMBERq
BDILO"° our ase ys ems 11096 APPLICATION.& PERMIT 41 O8
AODREss BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
070 , De Anza Blvd,
•� OWNER'S PLAN CHECK VALIDATION
"AME QTY. ELECTRIC PERMIT FEE
Four Phase SystemPAONE 255-0900
NAMERAcroRs - OUTLETS-SWITCHES-RECEP. 5.00/1.00
ORVIN ENGINEERINGLIC.ND150751 ILIGHTING FIXTURES 5.00/1.00
ADDTRACTDR's
ADDRESS APPLIANCES-RESIDENTIAL 4.00
3271 Kifer,Santa Clara 732-219 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.No.
OR
ENGINEER.
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
r' ZIP TEMP.METER OR POLE INS. 15.00 ^ ,
APPLICANT$ MOTORS SEE FEE SCH.
ADDRESS -
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION I{a//
a 0 U 1 hereby affirm (hat I am licensed under provisions of Chapter 9 ISSU NCE DATE
Z
a- (commencing with Sc0ion 7000)of Division 3 of tire Business and BLDG. ELECT. 11 PLG. MECH.
H m'^ Professions Code d/ny license is in(all fore 4
Z o v, Licen Clss o Lic.Number � u /-u 1 ❑ ,❑ ❑ ❑
H H Dale Contractor_URVJN1 N
a y s BUILDING PERMIT
¢ ¢ wu OWNER-BUILDER DECLARATION INFORMATION
wI hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALDATION $/FT.
F u o a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code.Any city or county which requires a permit to construct,alter,
$5 600.00
QQ¢ 0 Improve,demolish,Or repair any structure,prior tO its IssllanCC,JISO ELEC.CONTR. LIC.NO. ELEC.
D¢ requires the applicant for such permit to file a signed statement Ilia( TOTAL PERMIT TO
w $ he is licensed pursuant to the provisions of the Contractor's License C
Hit La..(Chapter 9(commencing with Section 7000)of Divtsion3of the
a BusinSecess and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
(C the hasis for the alleged exemption.Any violation c tion 7031.5
STORIES TYPE CONSTR.
i by any applicant for a permit subjects the applicantm a civil penalty ALTER-DRAIN IS,VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole 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
property who builds or improves(hereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided thin such improve
menu are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or mp
irovement is sold within one year of completion, the owner- GAS-EASYSTEM-OVER 4 IEA) 100 BUILDING USE
builder will have the burden of moving that by did not build or im . . .
- RES IND CON Pe olhb,
prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 20.00
CII,as owner or the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.'
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 -
contracts for such projects with a contraetons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA,200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. - ,BAP.C.lot this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ' ACC.DATE ACC.FILE NO.
WORKBRS'COMPENSATION DECLARATION - WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to sell'-insure. ZONING ENG.SITE N0,
or a certificate of Workers'Compensation Insurance,pr it certified
copy theregqffii($$eeyy ,,QQO��Irr'{{1yy,��). �s �
Policy No.S f1 2&dA _3-1NA/AETNA
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z �Fly jnrtilie til' -wiLL�.tILL.{ y i ggclJplt division. MISC.- REFER TO ORD. Y❑ IN y ❑ N[]A1(1+1a' lY.Ci1NE 1V li PERMIT ISSUANCE. 6.00 FLOOD ZONE A.L.U.C.
CERTIFICATE OP EXEMPTION FROM WORKERS'
_ COMPENSAT'ION INSURANCE PLG.CONTR. LIC.NO. PLC.
11 C IT his section need noj be completed if the permit is for one TOTAL v❑ NE] Y E] IN[]
D Z hundred dollars(SIBO)or less.) -
V O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,I shall not employ any person in any manner so as to
O become subject to lire Workers'Compensation Laws of California.
O i Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
56-00
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE 36 .73
U - such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOC.EM.) 5.00 SEISMIC FEE 50
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD IWITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT ITO 100,000 B.T.U.) 4.00
Lenders Name Nnne HEATI NG UN IT(OV ER200,000 B.T.U.)7.50
Lender's Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00
hereby.authorize representatives o1' this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpose
(We) agree to save, indemnify and keep mless the City of MISC.- REFER TO ORD.
Cupertino against liabilli ,judgments, cost�..�Idxpenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in a way accrue onst s
LC
q nee of the
gran Itis permit. MECH.CONT. LIC.NO. MECH.
/12 8 TOTAL TOTA14 L
n A cam/ a - 93.73
v
OFFICE COPY '