4714 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
BUT LD1 NG PROJECT I DENTI FICATI ON PERMIT.NUMBER
0V1DiNa SYVA P{OT 03-11111
AUDREsAPPLICATION & PERMIT 4714
0 Mariani Avenue BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"AME QTY. ELECTRIC PERMIT FEE
S va Corporation PHONE 466-996
CTRs
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
ORVIN ENGINEERINGIC.NO. 150,751 LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDREss
3271 Kifer Santa PGIara 732- 19 ANELS 5.00 DATE OF APPLICATION
RCHrtECT SIGNS 6,00 PLAN CHECK FEE P.C.NO.
O
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR END' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
:IP EMP. METER OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
0 o O LICENSED CONTRACTORS DECLARATION
r
G 1 hereby affirm that I am licensed under proision
vol'Chaps Chapter 9 ISSUANCE DATE
2 U
y (commencing with Section 7000)of Division 3 of tire Businees and BLDG. ELECT. PLG. MECH.
a H
H w z Professions Code,un license is in lull for u ❑ ❑ O ❑
z o m - License P Lia Number y�,l,!-.f, _
9 z w Date� .�Contractor_G 11V
a y BUILDING PERMIT
w ¢ OWNE ILBUILDER DECLARATION INFORMATION
REFERTOO
w3 LL H I hereby infirm that I am exempt from the Contractor's License MISC.- VALUATION $/FT.
HLoa Law for lite following reason.ISec.7031.5.Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requiresa permit Oennstric,alter, $'� 700 .00
rt X 4 oO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG N0.
ELEC.
- 0 rE requires the applicant for such Permit t°file a signed statement shat TOTAL PERMIT TO 76/j
A w m he is Iicmtsed pursuant to the provisions of the Contr:mtoi s License p
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe FIR 6- J 4I A,
< Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
c the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
Ca A3 - by any applicant for a permit subjects the applicant to a civil Penalty gLTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).1:
❑ 1,as owner of the property,or it,,employees with wages as BACK FLOW PROTECT.DEVICE 2.00 DCC.GROUP HES.UNITS
their sole compensation,will do the work,and the structure n 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 t ercon,and who docs such work FIXTURES-PER TRAP 4.00 50,FT FLOOR AREA TOTAL ACREAGE
• menisf re through his own employees•Provide)teas such inryrrne-
men ell re not inleaded oroemplofor sale.provide,
Tud .thebufldlpg GAS-EA.SYSTEM-1INC.4OUTLETS 4,00
or imp r..CHvvt is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PR Omer
prove for purpose nfsalc.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property.am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licmned 'tntmctors 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 does not apply
to:m owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts fur such projects with a Contmctorls)peeved pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft,16.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. .B.&I'.C'..lir this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK Ii RS'CO\1PFNSA'1'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsent to aelf-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified
copy thy,ryf{SaS..3 gAQ,1yb.0 INA AETNA
Policy h
anY
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z Certified COPY b Died with the City 'ISQCctlno division.
o 4Acant- rViX1_ ngueesing-Cor MISC. REFER TO ORD.
Y ❑ N Y ❑ N❑
M W CERTIFICATE OP I XESIPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LET > COMP(?NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (This section need not be completed if lire permit is for one TOTAL V❑ N❑ Y ❑ N❑
0 Z hundred dollars IS 100)or Iess.)
U O I certify that in the performance of the work for which this per QTY MECHANICAL PERMIT FEE
eFEE SUMMARY
LL F mit is issued,1 shall nut mploy-any Person in any trimer sa as to
U become subject to the Workers'Compensation Laws of California. BUILDING
U i Date Applicant ALTER OR ADD TO MECH. 4.00 38 5
Y W NOTICE TO APPLICANT': If,after making this Certificate rel'Ex-
FZ Cnlption,you should become subject to the Warkers'Compenati.R APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code. you most forthwith comply with FEE 25 .03
U such provisions or this permit shall be dcaned revoked. AIR HANDLING UNIT(TO 10M C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10A00C.F.M.) 5.00 SEISMIC FEE .50
1 hereby affirm that there is a construction lending agency I'or EXHAUST HOOD(WITH DUCT) 2.00
the performance of the 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 TCT^=6 HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
Icertifyth;nlhavuread this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all city and couin, PLUMBING
ordinances and state laws relating to binding construction, and
BOILER-COMP(3 H.P.or 100,000 B.T.U) 4.00
hereby authorize representatives .1 this ry to enter upon the BOILER-COMP IOvw 100,000 BTU)SEE FEE SCH. MECHANICAL
ahovrmeminneJ property for inspect ion urposes.
(We) agree to save, indemnify and cep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgment ubsts and expenses which CONST.TAX
may in y way accrue against sun (11in
11 consequence of the PERMIT ISSUANCE 3.00
gm this pcm l MECH.CONT. LIC.NO. MECH.
/_1.2 83 TOTAL TOTAL 6.4.03
Si R,of p ice ret,1Q)n ICCT.r Ucle
OFFICE COPY