2445 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION 1)44 PE MIT pyjR
ADDRI$$ Valley Green DriV AF1sLICATION & PERMIT _ _ 2 44 5
$ x BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWNER'$ Rancho De AnZa - ' ••r -- , ' F, PLAN CHECK VALIDATION
NAME. CITY. . •. ELECTRICPERMIT -'FEE
PHONE I - • 1. 4 '
NOrvrRAcroR3 UTLETS-SWITCHES•RECEP 5.00!1.00
NAME
Orvin Engineering 1_I1.ND.150751 ILIGHTING FIXTURES 5.00/1.00
ADDRESS
DoR sC anta Clara PPLIANCES-RESIDENTIAL 4.00
DREss
3271 Kifer Rd. PHONE 732-219 PANELS 5.00 DATE OF APPLICATION
ARCHITECT
OR SIGNS 6.00 PLAN LHECK FEE P.C.NO.
ENGINEER
LIC,NO SIGNS TRANS. 3.00
ADDRESS eea. SPECIALCIRCUIT 5.0Q PERMIT VALIDATION
zip TEMP.METER OR POLE INS. 15.00
AMOTORS SEE FEE SCH.
APPLICDDREAas
SERVICE CHANGE 10.00 Y�/��
Woo LICENSED CONTRACTORS DECLARATION
¢ u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N < i (commencing with Section 7000)of Division 3 of the Business anJ B CT. PLG. MECH.
F N i Professions Co a y license is in full for epIIA.6( I.
z O License la Lic.Number :JU / 1 ❑ ❑
9 m=w Date--? Contractor -
¢ y 2 I J1, 'PERMIT'fJ'"'.,
¢ ¢ w 4 OWNER-BUILDER DECLARATION -i N _ ATION,yv."' eikh:
a O c MISC.- REFER TO ORD C�':o-' chi' i .
X ;w r 1 hereby affirm that 1 am exempt from the Contractor's License
uO< Law for the following reason,(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00 y♦flf V{4sAk u��n_it 4�}N�I SIFT.,
r y y Cade:Any city or county which requirna permit loconsln-1 alter. ELEC. ly O/ /7 e 7 JO U
re a, Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. 4
E O LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E
$ he is licensed pursuant to the provisions of the Contractors License 1
r 2 mac$ Law(Chapter 9(commencing with Section 70001ofDivismn3afthe
FEE'M
Fire Sprinklers
PLUMBING PERMITBusiness and Professions Code)or that he is exempt therefrom and
¢
the basis for the alleged exemption.Any violation of S,ction 70315 'aM4f w.4rsc- -s.� 1 nvl.. 4.^-r /. ...,R aCM STORIESTYPE CONSTR.
by any applicant far a permit subjects the applicant toa civil penalty •ALTER-DRAIN&VENT-WATER IEA.) 4.00
of not mare than five hundred dollars 05001.1:
❑ 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 thereon,and who does such work FIXTURES-PER TRAP 4.00 s0.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
;� meats are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM•OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im. RES IND CON PB Ornar
prove for purpose of sale.). INDUSTRIAL 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 NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
C I am exempt under Sec. .B.BP.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKFRS'COAIPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG,517E NO.
Copy ther
Policy NO. 000965/Argpnau
O ❑ Certified o y is hereby furnished. q FIRE SPRINK ENERGY T24
Z 2 Certi py is I�y ins ect division.
O MISC.- REFER TO ORD. Y C] N❑ Y [3N❑
AppTica
Cr T1.KATE OF EXEMPTION FRO 7 WORA KERS' PERMIT ISSUANCE 6.00 F400D ZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
Q. (This section need not be completed if the permit it for one TOTAL Y F] Car C] Y ❑ N❑
D Z hundred dollars(SI00)or less.! "Y'; " "..,- t - '� ";� 1 -
U O 1 certify that in the performance of the work for which this per- _ - FEE SUMMARY ' � ""
LL H mit is issued.I shall not employ any person in any manner so as m CITY' .e..I MECHANICAL PERMIT - FEE;, f r Y. x+•. .r...
U become subject to the Workeri Compensation Laweof Calil'omia.
CU Date ApplicantALTER OR ADD TO MECH. f 4.00 BUILDING 50.50
} H NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F.. ? emption,you should become subject to the Workeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply withFEE 32.83
C.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO lo=r_F.NL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=12-F.M.) 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,CN.C.). HEATING UNIT ITO 100,000 B.T.U.) 4.00 P
Lenders Name ...-..None HEATING UNIT(OVER 100,000 B.T.U.P.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information correct I agree to comply with all city and county -PLUMBING
dinan
uand state laws relating to building construction, and 80ILER-COMP(3 H.P.or 100,0008.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IOvar 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of misc.- REFER TO ORD.
Cupertino against liabilities,judgments, Wits andexpenses which CONST.TAX
may i any way accrue against Said ypy in consequence of the PERMIT ISSUANCE 3.00
grant of this permit.�.., MECH;CONT. LIC.NO. HELM. e. .Ys �'Pq
9 14 8 OTAL ``TOTAL �+" 83. 33
nature of Applicant/Contract Date 1'
J mes W. McGrego , Vice President OFFICE COPY