2837 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PER TNU
BU I LDING PROJECT IDENTIFICATION APPLICATION & PERMIT
BUILDING
HEWLETT PACKARD 03-10622 37
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
AR OWNER'S �' _ .p, VALIDATION
NAME QTY. �1%' y" ELECTRIC PERMIT FEE'
Hewlett Packard P...E257-7000. L. "
CONTRACTOR'S 12286 UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
ORVIN ENGINEERINC,c NP. 3368 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'8 anta Clara 95051 APPLIANCES-RESIDENTIAL 4,00
ADDRESS
3271 Kifer Rd. 1HONE732-2192 PANELS 5.00 DATE OF APPLICATION
ARCHITECT
SIGNS 6.00 PLAN CHECKFEE P.C.NO.
OR
ENGINEER SIGNS TRANS. 3.00
LIC.NO. PERMIT VALIDATION
ARENG. SPECIALCIRCUIT 5.00
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT s MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
w
02 LICENSED CONTRACTORS DECLARATION
v u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
I—< a (Commencing with Section 7000)of Division 3 of the Business and rB�LDG. T. PLG. MECH.
O i ProfessionsCod .an license is in full f c f¢ oHcse C�asZ Lie.Number �-,o z colnrac[mNG
L INGY,ERMITat ¢w ¢ OWNER-BUILDER DECLARATION RMATIONA a A. 0 MISC.- REFER TO ORD
g LL vi I hereby affirm that I am exempt from the Contractors License N SIFT.
w D¢ Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00� -1 Code:Any city orcounly which requires a permit to construct,alter. 00ceat a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.0 requires the applicant far such permit to file a signed statement that TOTALMIT TOw$ahe is licensed pursuant to the provisions of the Contractors License> Law(Chapter9(commencingwithSection7000)ofDivision3ofthe ! .l'PRiNKBusiness and Professions Code)or that he is exempt therefrom and OTY. .,PLUMBING PERMIT gy•,
¢ H $ the basis for the alleged exemption.Any violation of Section 7031.5 ` _ "� %" .;" - - - r'rl ": I,.P! .."' DT' S TYPE CONSTR.
i g by any applicant for a permit subjects the applicant oa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not moa than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00 CC.GHDUP RES.UNITS
their sole compensation,will do the work,and the structure is nod
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 SG.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-11NC.40UTLETS q.00
meats arc not intended or offered for sale.If,however.the bolding
Or improvement 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 Pe Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
❑ I,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 contracro O licensed pursuam to SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sec.-.BAP.C.for this WATER HEATER W/VENT 4.00
reason
Dine Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE N0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy there �,,ped�65 Ar9nna11t
Policy N rt �+,t15
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-]<
❑ Certified copy 's filed with the city inspection division. MISC.- REFER TO ORD. y❑ ry❑ y ❑ N❑
♦: O mow.-a...:.-+ NQINPESR�•NG-G0R-P
Applicant FIA VTNT FN!"
CCN CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (This Section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ INC)
2 hundred dollars IS 100)or less.) "' ti' ' ' a s;Js 'v f a�1FEE'SUMMA_. r•�rpe
U 0 1 certify that in the performance of the work for which this per QTY.? MECHANICAL-PERMIT, • FEE; ++a ,P.,, . .,
U. F mil is issued,I shall not employ any person in any mannersc .Ism "r,
-° v' ,� tf.r ";'.+ '� .'ti": . "f s W h:••
O W become subject to the Workers'Compensation Laws of California BUILDING 32.50
Dade Applicam I ALTER OR ADD 70 MECH. 4.00
>_ N NOTICE TO APPLICANT: If,after making this Certificate of Ex- '
F.. ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK 21.13
provisions of the Labor Cade, you must forthwith comply with AIR HANDLING UNIT(7010 QF.M.) 3,00 FEE
C..) such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING,AGENCY AIR HANDLING UNIT(OVER 10DWC F.M.) 5.00 SEISMIC FEE .50
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(See. HEATING UNIT(TO 100,008 B.T.U.) 4.00 MICROFILM
3097,Civ.C.). None
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50
Lenders 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(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify a keep harmless the City of MISC.• REFER TO ORD.
Cupertino against liabilities,judgm• Is. casts and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in a ;w.y accrue against i City in consequence of the
gmnf g thper MECH.CONT. LIQ NO. MECH.
TOTAL 54
sig o plieantl m a e .13,
aures W. McGregor, Vice President OFFICE COPY