7093 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENT[FICATI ONy PERMIT NUMBER
ADDRESS ,7,f'7.. 1r.�G _�. ti /,� APPLICATION & PERMIT 7093
ADDRESS
r BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
u
OwNER's'��� � PLAN CHECK VALIDATION
T NAME _ -� ,d�,�. QTY. ELECTRIC PERMIT FEE
1 ! �A�n_ n ?ROSE ) i 7. J! l
's
NAME CONTRACTOR
/ f OUTLETS-SWITCHES-RECEP -5.00/1.00
N
LIODO LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADO(REEss /
(,PRUNE ,� n l�- rfrl�`C PANELS 5.00 DATE OF APPLICATION
r
-ARCHITECT J SIGNS 6.00 PLAN CHECK FEE PX,NO.
OR /
ENGINEER
' LIC,No, SIGNS TRANS. 3.00
ARCH,ss ENC' SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 15.00
ACANTS
ADDDRESSDRESS MOTORS SEE FEE SCH. S
SERVICE CHANGE 10.00
o o LICI' - CONTRACTORS DECLARATION C/
Q Be p I hereby afrmfithat I am licensed under provisions of Chapter 9 ISSUANCE DATE
I a w (commencing with Section 7000)of Division 3 of the Busincss and BLDG. ELECT- PLG. MECH,
F N i PRAT ions Code,and my license is in full force and effect, y ❑ ❑ ❑ ❑
Oz License Class !g Lie Number Nit -
O z - 07 Date
/ - _� - Contractor N� 't -
a Y s -a h� BUILDING PERMIT
¢ rt w Q OWNER-BUILDER DECLARA[ N INFORMATION
a ora " MESO-- REFER TO ORD
w S LL r I hereby affirm that I am exempt from the Contractor's License VALUATION SIFT.
H e_ o g Law for the following reason.(Sec.7031.5,Busineuar Pro fissions PERMIT ISSUANCE 6.00
cp Code:Any city or county which requires a permit to construct,alter, 361-0
rc 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE LIC,NO. ELEC.
an
- O m inquires the applicant for Such permit to file a signed smtemmfl that .. TOTAL PERMIT TO
u w or be is licensed pursuant to the provisions of the Contractors License
FZQLaw(Chapter 9(commencing with Section 7000)ofDonsien 3 ofthe
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
ar F m the basis for the alleged exemption,Any violation of Section 7031,5 STORIES TYPE CONSTR.
a _ by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.) 4.00 ME"�, S f�R Kc
of not more than Lrve hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 4 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 aY '
Code:'Phe Contractor's License Law dues not apply to an owner of �..-
properly who builds or improves tltercon,and who docs such work FIXTURES-PER TRAP 4.00 SO,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such'in
prove-
inemsare not intended oroffered for sale,If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner- GAS-EASYSTEM-OVER 4 (EA) 100 BUILDING USE
builder will have the burden of proving that h . . .
e did not build or int- RES IND CDN PR Oma.
PO forPULP s owner of the INDUSTRIAL WASTE INTER. 20.00 -❑ ❑ ❑ ❑ ❑
❑ L as owner of the property,he exclusively project
(Se . 7044,ing with
licensed contractors to construct the pLijen (Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL No.
too owner ns property Contractor's License Law does not apply
to tr owner of property who ba cont r improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts leu -'s L projects with a contractor(s)licensed pursuant to '
the Contracmr's License Law. _ SEWER-SANITARY-STORM EA.200ft/8.00 'b' TRACT No. PARCEL NO.
❑ Iran except under Sea .B.&P.C,for this WATER HEATER W/VENT 4.00 �' I
raison
owner Date WATER S3STEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPEN'SA)'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby uf(irm that 1 have vi certiGn, toof consent to s,H4in,ure,
r a eertifcme of Workers'Compensation Insurance,or u certified ZONING ENG.SITE NO.
'opyIf (Sec,3800,fah C.T �} // /
Policy No,/l 1<•1v C� rp
many >.-•/r l!'xd�r'/Tn11q
0 ❑ Certified entry Is hereby lurni,hed. FIRE SPRINK ENERGY T-24
z Z ❑ Certified�cro,y. is fled with the city e inspeEtion division.
O_-? Applicant x'/ � f✓ MISC.- REFER TO ORD. Y ❑ ;N❑ Y ❑ N❑
~ w / PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
y CIiRTI PIC ATR OF EXEMPTION FROM WORKERS'
W > COMPIiNSATION INSURANCE PLG,CONTE. LIC.NO. PLG.
EL 1)( This section need not be completed it' the permit is for one TOTAL �� Y❑ N Y ❑ NEI
hundred dollen($100)or less,)
U O 1 certify that in the perforemore of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
EL b- mit is issued,1 shall not enploy any person in any reannerso as to
U beconm subject to the Workers Compensation Laws of California.
O LU Date Applicant BUILDING l,C f4�6-
CL ALTER OR ADD TO MECH. 4.00
} So NOTICES 10 APPLICANT: If,after inking this Certificate oI'Ex-
Z Cngnion,you should become subject to the Workers'Compensatimi APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be devoted revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10A00C.EM.) 5.00 SEISMIC FEE ,LTJ
1 hereby affirm that there is a construgion lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the perfoummrre of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.T HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that l have read this application and slate that lire above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING Q t�
endurances and slate 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 IDver 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, Costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
grantil� urs permit , ,�' MECH.CONT., LIG NO. MECH,
y b N orAL TOTAL
Si url of Applican l/Contractor, Date
i INSPECTOR COPY