5726 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' PERMIT NUMBER
BUI LDI GPROJE IDENTIFICATION, /APPLICATION & PERMIT
agpmtL�+owc 5726
LV�bU SC8Y8II8 Cr88IC Blvd. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
•
Cupertino City Counter
CONTRACTORS
NAME UTLETS-SWITCHES-RECEP 5.00I1.00
OrVin Eng. Corp. LIC.NO. 150751 LIGHTING FIXTURES 5.00/1.00
CCONTRACTORS ons 1''TBEIOIIt� ('iA 94538 PPLIANCES-RESIDENTIAL 4.00
ONTRA L
4077 Pestana P1 . PHGNEb51-1 71 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS g PLAN CHECK FEE P.C.NO.
OR
ENGINEER
� LIC.NO. SIGNS TRANS. - .3.00 .'
moo Esi ENG. SPECIAL CIRCUIT x..'5:00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 It
ADDRESNTs MOTORS SEE FEE SCH. /J /
SERVICE CHANGE 10.00
,-00 LICENSED CONTRACTORS DECLARATION
Q U e~i 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 and BLDG. ELECT. PLG. MECH.
F m i P,oIrssiom Cod ny license is in full Ia ❑ ❑ ❑ ❑
CT5 "1�b�51
0 o m License(I� Lie Number
o y r w 1) O��$-�Contract. _0AVz f
a¢ a OWNER-BUILDER DECLARATION BUILDING PERMIT
- a m D INFORMATION
E:
O lL I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
3 u y VALUATION $/FT.
F LL
04 Law for the hollowing reason,(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires permit toconstmeL alter,
rtwQ Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC.
R 0 ac
requires the applicant for such permit to file a signed statement that - TOTAL PERMIT TO
a m he is licensed pursuant to the provisions of the Contractor's License ./
FziIaw(Chapter 9(commencing with Section 7000)of Division 3 of the F�aec rLixs/i�/"r
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
I. r•o the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
aim hyany applicant ora permit subjects the applicant Ina civil penally ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dullars(S5001.):
❑ I,as owner of the property,or my enlpluyces with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GRouP RES.urvlTs
theirsWc conspewatinn,will do the work.anA the structure isnot
intended or offered for sale(Sec. 7044, Business and Poneseiorns 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 So.FT FLOOR AREA TOTALACREAGE
• himself or Daough his own employees,provided that such improve-
mcutsarenotintendedor.offered foreale.if,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
OF inquovereeot is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 IEA) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or am- - . .
RES IND CON PB Omer
prove for purpose of sale.). - INDUSTRIALWASTE INTER. 20.00
Cl 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 Codc 1'he 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
contrails forsuchicenL
License Lecaw.with contracmr/s)licensed pursu�ntm
tit Contractors LicenSEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sce. ,BAP.C.for this WATER HEATER W/VENT 4.00
reallnl
Owner ])ate WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSAI]ON DIfCLARA'I[ON WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certifileme of consent to sell-insnm,
ora ecuifieale of Workers'Compensation Insurance,or u certified ZONING ENG.SITE NO.
copy thersof(See 3800a�Lab r.).
Policy No.-C.1-7a'pp4 pyo�A TA -ASCE A-
O Certified copy is fihh reoy fumrsheJ. FIRE SPRINK ENERGY T$4
CeNdi �p g is IIIy.uLy�I 'he
1 ins ection division.
zp Applicant-ryin fJNglneO 1.`iw MISC.- REFER TO ORD. Y❑ N❑ Y N❑
cc: y ' CER'I'IFICATi-OF ESRM PTION FROM WOR K ERS. PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
LU > CO.IPENSAIION INSURANCE PLG.CONTR. LIC.NO. PLG
� Z J none dollars
need not be connplC¢•J if lire permit is for one TOTAL
Y❑ N❑ Y❑ N❑
hhndreJ dollars($100)or less.)
U O i 1I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
F
LL mit is issued,1 shall not employ any person in any manner NO as to
U Ibeconm subject to the Workers'Contpensal ion Laws of California.
Q a D:IIc iApplicant ALTER OR ADD TO MECH. 4.00 BUILDING
>- m 'NIOl ICI:'f0 APPLICANT: If,after making this Certificale of Ex-
F Z enlption,you,should become subject to the Workeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor.Code, you nmst forthwith comply with FEE32 . 83
U r (such provisionsor this permit shall bedeviled revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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 pintormance of the.work for which this permit is issued(Sec. MICROFILM
r� L yi7 iv.C.). $pJFJ Of Amer;ca NT¢S HEATING UNIT(TO 700,000 g.T.U.1' 4.00
/ Lcndcr's Name�7�. + , A-A'
hcndcr s Addre,< 9-L"T"O 0'8-p; HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I ecrtily that Phave read thisapplicution and stale that the above VENTILATION FAN (SINGLE) 3.00
informmion is correct. I aIocc to complywith all city and county PLUMBING
ordinancros and irate laws relating to building n'mstreclion, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00
hereby authori a representatives of this city hn enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
./ abovomenvioned property for inspection purposes.
1 (We) agree to save, indemnity and keep harmless lire City of MISC.- REFER TO ORD.
ft Cupeffno against!liabilities,judgnnenls, cases and expenses which CONST-TAX``' Ray in any wayl accrue against said City in consequence of the PERMIT ISSUANCE 3.00
TI
get this ennit. MECH.CONT, LIG NO. MECH.
y AYto �I. x;al /14/85 TOTAL
TOTAL 83.83
` pliG o r Datc
INSPECTOR COPY