7093 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING I APPLICATION & PERMIT _ 7093
.
/- BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
GAVEn's y'y/ PLAN CHECK VALIDATION
HONE
1�T NAME ..
�a CITY. ELECTRIC PERMIT FEE
CONTRACTOR'S
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
�Ic.rvo. LIGHTING FIXTURES 5.00/1.00
\ roNTRAcTOR's PPLIANCES-RESIDENTIAL 4.00
Y. ADDfl E55
•Ale HorvE — PANELS 5.00
aNCIlITECi , DATE OF APPLICATION
GR
ENGINEER SIGNS 6,00 - PLAN CHECK FEE P.C.NO.
LIc.No.AENG. SIGNS TRANS. 3.00
ADDRESS SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP,METER OR POLE INS. 15.00
ADDRESS MOTORS
ADDRESS SEE FEE SCH.
SERVICE CHANGE 10.00
o a i
IT o o LICENSED CONTRACTORS DECLARATION <0 '
a u is I hereby affirm that 1 am licensed under provisions of Chapter 9
w a "' (commencing with Section 7000)of Division 3 of the Business and ISSUANCE GATE
r w Professions Code.��gggqd my license is in full fort e( c ?• BLDG: ELELT. PLG. MECH."
z o w - License Class Lic.Number 1 ❑ 11F-1 ❑
•O m f �/ Ualc_/ {fL( Conlrador
a y E J
¢ ¢w a OWNF R-BUILUF:R UECLARAT ON BUILDING PERMIT
u INFORMATION
w ;` N 1 hereby uffinn that I am exempt from the Contractor's License MISC.- REFER TO ORD -
F .. oa Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE vALUATIO S/FT.
m i J Code:Any city or county which requiresa permit toconstrucl,alter, 6.00 pZ3
¢ ¢ a oLd
p improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. •J
¢ requires tire r
e applicant for such pemit to Isle a signed statement that TOTAL
a w m u he is licensed pursuant m the provisions of the Contractor's License
�z >
Law(Chaplet 9(commencing with Section 7000)of Division 3 of the 7SQ.FT.FLWRARkA
Business and Proessions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation ofSection 7031.5q,
by any applicant for ive hun re suGl1mEects S5 applicant loacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00atom mare than five the prop rty,o(5500)_): 1das owner of the properly,or my employees rich wages as BACK FLOW PROTECT. DEVICEtheir sole compenmfion,will do the work,and the slmClure is Hol 2DD S.UNITSintended or offered (or 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 ofproperty who bunds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 TOT
aeREAG.
himself or through his own employees,provided that such improve-
mentsarenotintendedcrorfered for Sale.If,however,the building GAS-EA.S(STEM-1INC:4 OUTLETS 4.00
or improvement is sold within one year.I'completion,file owner-
• builder will have the burden of proving that he did not build or ice- GAS-EA.SYSTEM-OVER 4(EA.) 1,00 BUILDING USE
prove for purpose of tiled. INDUSTRIAL WASTE INTER. - 20,00 REs IND. CON PR Omar
❑ L as owner of tire property,he exclusively contracting with ❑ ❑ ❑ ❑ • ❑
antisedPro contractors to construct the project(Sec, 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00
and Professions Code:The Contractor's License Law does not apply ASSESSORS PARCEL NO.
to an owner or property who builds or improves thereon,and who - LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with u contractuds)licensed pursuant to
the Commcmr's License Law: SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt m&rSec. ,B.&P.C.for this
reason WATER HEATER W/VENT 4,00
Owner Date WATER SYSTEM
.4.00 ACC.GATE ACC.FILE NO.
WORKIiRS'COMPENSATION DIiCLARATION WATER TREATING EQU 4.00
I hereby off nn that 1 have a certificate of consent to self-insure,
r a certificate of Workers'Compensation Insuru¢e, r a certified ZONING ENG.SITE NO.
vpy theregj'jS�ec._3 0y,Lob.C.). -
Policy No/ISSOl2ipmr
O ❑ CerliOed copy is hereby furnished
z ❑ CeHific Is Ie th t mspeclion division. Inn FIRE SPRINK ENERGY 24
FO Applicant lSf� MISC.- RTO ORD. Y❑ N❑ Y ❑ N
h CERTIFICATE :IiXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00T71 FLOOD ZONE a.L.U.C.
LU
Q COM iNSAT10N INSURANCI° PLG.CONTR. LIC.NO. PLG ,
Z CI his section need Hol be completed if the permit is for one TOTAL 0 Y❑ N❑ Y E: ry❑
U O hundred dollars($100)orlessJ
I certify that in the Perfarmunce of the work for which this per, OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,1 shall not employ any person in any manner so as to
O Wbecome subject to the Workers'Compensation Laws of Califomia.
Q. 'Dale ApplAPPLICANT
ALTER OR ADD TO MECH. 4.00 BUILDING eZ//G a`
} Z NOTICE TO APPLICANT': If,aftersubject
making this Certificate sa ion
— provision you should become subject to the Workers'Compensation APPLIANCE 400 PLAN CHECK
provisions the Labor Code, you must forthwith .
comply with
U such provisioio ns or this permit sham
ll be deemed revoked. AIR HANDLING UNIT(TO 10p00GF.N1.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 5.00 SEISMIC FEE —0
I 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.
3097,CN.C.). HEATING UNIT IT MICROFILM
O 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that l have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING Q
ordinances and state laws relating to building construction,and BQILERF13 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes, BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save.,indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any y acctq against said City in consequence of the PERMIT ISSUANCE 3.00
gmnlit lis permit.,/ _ n MECH.CONT.- L.I.NO. TOTAL —L)9
�Jj�JIMECH TOTAL
Si lure of Ap ¢ant/Contractor Date "
OFFICE COPY