5724 APP ILICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION- PERMIT NUMBER
APPLICATION $! PERMIT
ADORE,, Cupertino City. Center/T nants
0300 Stevens Creek Blvd 5�� /�•BUILDING - ELECTRICAL-PLUMBING-MECHANICAL k{
OINNEH'5 ' + L ` PLAN CHECK VALIDATION
NAME OTV9 riv`ELECTRIC'PEf2MITa.`r+,yw, x �,FEE"q;
Cupertino City Cewtler Assoc , 'B
NAMERAcroRs OUTLETS-SWITCHES-RECEP 5.00/1.00
RVIN ENGINEE RING Lt..NO. 150751 LIGHTING FIXTURES 5.00/1.00
ADDESS TOlrs Fremont , CA 94538 APPLIANCES-RESIDENTIAL 4.00
077 Pestana P1 . 4151/651-177 L PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER '
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG SPECIALCIRCUIT 5.00' PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
ADDRESS - - MOTORS SEE FEE SCH. )
ADDRESS
SERVICE CHANGE 10.00 p _
r o o LICENSED CON'rRACfORS DECLARATION
v w I hereby affirm that 1 am licensed under provisions of Chapter') ISSUANCE GATE
w (commencing with�pSection 7000)of Division 3 of the Business and
a N ftU � BLDG. ELECT. PLG. MECH.
f w z professionsasCie C d ¢dost is in full force and -1-6 ❑ ❑ ❑ ❑
z o w- License Clasv Lic.Numher_(„'-1 6
o T t W Date.D C-._7_---4.11B 4tnclnr-0 R*I N-E-N'G I E E I N G
a V 2 'BUILDIN011PERII
O n 0 OWNER-BUILDER DECLARATION 7w N
m 3 u . I hereby affirm that I um exempt from the Con tractors License MISC.- REFER TO ORD INFORMATION
r .. O er Law for the following reason.(See 7031.5,Businessand Protrusions PERMIT ISSUANCE VALUATION S/FT.
6.00
Code:Any city or county which requires a permil to construe(,alter, O
SE a,¢0 improve,demolish,or repair any structure,prior to its issuance,else ELEC.CONTR. LIC.NO. ELEG 21
O o: requires the applicant for such permit to File a signed statement that TOTAL
n w m u he Is licensed pumumH In the provisions of the Contractors License or
TO
r i Law(Chapterand
Professions
Cod )lh Seel that lie 7000)ofDiheref o , lir 9 i+� , „ ' t4 4, �
Business and Professions Code)or that he is exempt therefrom and GTY. 4,TIy sL .PLUMBING PERMIT l FEE
F_m the basis for Ore alleged exemption Any violation of Section 7031 $ ,"I;'§�'h am* 4 a STORIES TYPE CONSTR.
i ; - by any applicant for a Permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than Fie.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,CON D. 4.00
Code:The Contractors License Law dols not apply to an owner of
property who builds or improves thereon,and who dress such work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such tnspiove.
mems are not intended or offered for sale.If,however,[tie building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that be did not build or im. GAS-EA.SYSTEM-OV ER A (EA.) 1,00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON pe Omer
C1 1,as owner of the properly,am exclusively contracting with ❑ ❑ '❑ ❑ ❑
licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 A55ESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the C'omractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ tum exempt under See- ,B.&P.C.for this WATER HEATER W/VENT 4,00
reason
Owner Dare WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKS RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to sel Ginsure,
or a certificate of Workers'Compensation Insurance,or it certified ZONING ENG.SITE NO.
copy ther e g 0 L b.C. .
policy Nr-�1d�Ga RTS-INA-/-AET-N-A
0 ❑ Certified copy is hereby furnished.
Z Z 7ct- LCertil'irl)R'VTN Et xWNJr'f�u:.�ity�igsg�CJjon division. MISC- REFER TO ORD. . VIRE SPRINK ENERGY T-2
0 r[� 6 LY b 1 lV tS L` n�1V l ❑ ❑ ❑ ❑
it y PERMIT ISSUANCE 6.00
� - CEIi'I'IFICEXEMPTION PROM WORKERS' FLOOD ZONE A.L.U.C.
W COM� COMPENSATION INSURANCE PLG.CONTR. LIC.N0. PLG.
= a (Phis scelion need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
hundred dollars($100)or less.)
C.) 0 1 certify that in the performance of the work for which this per- - i w a +-eFEE SUMMA Y
LL F ml n issued,1 shall not employ any person in any manner so as to QTY.C '`L•�",' .MECHANICAL"PERMIT r#�s µFEE.!i
O L) become subject to the Workers'Compensation Laws of California.
a Dme Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} a NOTICE 'f0 APPLICANT': If,ufie,making this Certificate of Ex38. 50
-
F Z cmp(ion,you should become subjoct to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you Rmsl Forthwithcomplywith FEE 25 , 03
U such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(To20p000.F.M.) 3.00
CONSTRUCTION LENDI NG AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE , 50
I tuureby affirm that there is a construction lending agency fur EXHAUST HOOD (WITH DUCT) 2.00
the erformance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C). Bank of AMeri Ca NT&SP HEATING UNIT ITO 100,000 B.T.U.) 4.00
Lenders Name
Lender's adrev �y On Vg. .� Alt(JiEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that l have read this r pplicd ion and state Hirt theabove VENTILATION FAN,(SINGLE) 3,00 -
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and slide laws clating.to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over!00,000 BTU)SEE FEE SCH. MECHANICAL
aboveanentioned propAinspectii t Poses.IWO ogre, to srv• r R harmless the City of MISC.- REFER TO ORD.
Cuperti gainst six and expenses which CONST.TAma any way ccty in Consequence of the .PERMIT ISSUANCE 3.00Hi his er LMECH.CONT. UC.NO. MECH.12 7 84 TOTALTOTALSi a re slApptDrtc -
OFFICE COPY'