4716 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING "'CITY' 'CENTER 03-11140
APPLICATION & PERMIT 4716
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
O fl °' . "k. n + "�•`�'�'dT,,�tyo- :ACa - PLAN CHECK VALIDATION
NAME Cupertino City Center OTY.,+_ 'ELECTRIC PERMIT {-� _{i'i-w. FEE.
AssociatesB PHONE C•1 fv "'-=_1 µ
• LONTRAOTOR'5 OUTLETS-SWITCHES•RECEP 5.00/1.00
NAME
ORVIN ENGINEERINGD.No 150.751 LIGHTING FIXTURES 5.00/1.00
ADDRESS
NTRACTOflS Fremont, CA 94538 APPLIANCES-RESIDENTIAL 4.00
4077 Pestana P1. 413aEi/651-1771 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK F7 P.C.NO.
Ofl
ENGINEER LOC. J 00
LOC.xo, SIGNS TRANS.
ARCH.OR ENG. 5.00
PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
Woo LICENSED CONTRACTORS DECLARATION
a u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H w (commencing with Section 7000)of Division 3 Of the Business andBLDG. ELECT. PLG. MECH.
i Profmions Code,a license is in full fo a 17Q I,
Licen 1 Lic.Number \1�� I ❑ ❑ ❑ ❑
Z ,H w Date Contrector ee ng
LDING PERMIT." "
Or m OWNER-BUILDER DECLARATION -'- INFORMATION:''
REFER TO ORD
LL I- I hereby affirm that I am exempt from the Contractor's License MISC.- ✓ -VALUATION S/FT.
w0� Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00
at Code:Any city or county which requiresa permit to construct,alter, Q
<0O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG.NO. ELEC.
AUG
G `• 911•0 0
0,
requires the applicant for such permit to file a signed statement that TOTAL F1 PERMIT TO
E
rn he is licensed pursuant to the provisions of the Contractor's License f-
Fzs Law(Chapter 9(commencing with Section 7000)of Division 3 of the n .c "r '' v J' •" _ pts
a Business and Professions Code)or that he is exempt therefrom and QTV k'.: PLUMBING PERMITa, 6a1 fitr I ��C
the basis for the alleged exemption.Any violation Of$ection 7031 $ 9 J > ".�_'4w -S'L' Su^dx +T d'" PA + N° STORIES TYPE CONSTR.
a ';; •. by any applicant for a permit subjects the applicant to a civil Family ALTER-DRAIN&VENT-WATER (EA,14.00
of not more than five hundred dollars(5500).):
❑ 1,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
properly who builds or improves thereon,and who does such work FIXTURES•PER TRAP 4.00 SG.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
homsare notintended oroffered for Sale.If.however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4,00
or improvement is sold within one year of completion,the owner- GAS•EASYSTEM-OVER 4(EA.) 100 BUILDING USE
builder will have the burden of proving that he did not build or im- . .
RES IND CON PB Other
prove for purpose of sale.). INDUSTR IAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL N0.
and Professions Code:The Contractors License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPR INKLERS-OV ER 5(EA.) 1.00
worn[s forctor'shcenecLwithacomractoRs)licensed pursuant to SEWER-SANITARY-STORM EA.2008/8.00 TRACT_NO. PARCEL NO.
the Contractor's h projects
Law.
❑ lam exempt under Sec.-.BAP.C.for this WATER HEATER W/VENT 4.00
reason
Dale Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure' ZONING ENG.SITE N0.
or a certificate of Workers Compensation Insurance,or a certified
copy thereo ( c.3 0 ,tLab. .L
Policy
IIp'I� INA/AETNA
0 ❑ Certified copy is here yfurnished. FIRE SPRINK ENERGY T-24
Z 2 }( Vertified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O pp(G'c--anl�,E'V3.n E'n Q3,F1ea.,r, Y ❑ rv❑ v ❑ N❑
Ny PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
ku CERTIFICATEOFEXEMPTION FROM WORKERS'
W COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG. Y❑ N❑ Y❑ N❑
OIL O (This dollars
need not be completed if the permit is for one TOTAL
Z hundred
ertify hat(5100)pe less.) -' > tt-
U O I certify that in the performance Of the work for which this per- " 7" J FEE SUMMARY. "L r
LL F mit is issued.1 shall not employ any person in any manner so as to QTY. MECHANICAL PERMIT. FEE'
U became subject m the Workers Compensation Laws of California.
� w Date Applicant •A`TER OR ADD TO MECH. 4.000. BUILDING 438SO
} Dr4 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
U such provisions or thispermirovisions of the Labor CGtshallbedeemedrevokedou must forthwithoomplywith AIR HANDLING UNIT(TO 10J"C.F.M.) 3.00 FEE 284.70
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.l. Bank Of America NT&S HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lancer's Name HEATING UNIT(OVER 100,000 B.T.U.17,50 ELECTRIC
Lender's Addressl ton
I certify that l have read thIs application and stme4hat IT; VENTILATION PAN (SINGLE) 3.00
• information is correct.I agree to comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100.000 BTU)SEE FEESCH. r MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and a harmless the City of MISC.- REFER TO ORD.
Cupert' against liabilities,judgment co s and expenses which CONST.TAX
may y wa cc OR, ainst sa' it in consequence of the PERMIT ISSUANCE 3.00
g in flhls per I. �/ MECH.CONT. LIF NO. TOTAH.
L ,M1". " •'" r
411 TOTAL,;'
ftuilst pliC /C ran ale
r
OFFICE COPY