5093'I APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
Lp
BU LDI NG PROJECT I DENTI FICATI ON t
BUYING APPLICATION & PERMIT - 5093: '� -DF �.k
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bx B� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
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NEh+n/z.q. L4Z4 Cf'ips) OTY. ELECTRIC PERMIT FEE
. PLAN CHECK VALIDATION
MF I�� Co. PRONE 28O_rGY^V
NAMERAcrORs 737 UTLETS-SWITCHES-RECEP 5.00/1.00 3-ro.CC
Co,\IA"E4 El LIC.NO.C-'O ►SS128 'L LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS �.-,.,,^ � ' I �I,�J '0
'1V Zs LF1#loru) J' . PHONE 7-$728 I3 PANELS 5.00 DATE OF AP LIGATION
ARRCHITECT SIGNS 6.00 Pt.ANCHECK FEE P.C.NO,
ENGINEER
I-C..NO, SIGNS TRANS. 3.00 ,
ARCH.04 ENG. SPECIALCIRCUIT. 0 PERMIT VALIDATION
ADDRESSZIP EMP.METER OR POLE INS. 0
APPLICANTS 1,Z MOTORS
ADDRESS
2,5 L.ECRO" Sr- II V.LFtJ,CP1r- SERVICE CHANGE 0.
o o 13
LICENSED CONTRACTORS DECLARATION J.
�54
<v I hereby affirm that 1 am licensed under provisions of Chapter 9 N,� VNC ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business und -
H¢Z BLDG. ELECT. PLG. MECH.
r y z Professions Code license is in Full three Ao�L,�fC�e�d F„(,�'T, 3.0 ❑
Z i w License Cle. e_ L_Lie.Number_1_2�a�O E]
Date Contractor ALM r L
¢ Y sL'�C11'41.L- BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLA^A' ON -
tc ar u INFORMATION
F
;A I- 1 hereby affirm[hut I am exempt from.the Contractor's License RISC.- REFER TO ORD
b VA WATON $/f T.
r u o J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 („00
F wieZ Code:Any city or county which requiresa permit to construct,alter,
IF ac ¢ D Improve,demolish,or repair any structure.pN[II to Its Issuance,also ELEC.CONTR. �� Q����LIC.NO. LEC. �pj x�
wO ¢ requires the applicant for such permit to file a signed statement that Y AILA-64 LSD �L DEAL �v�- PERMIT TO
$ he is licensed pursuant to the provisions of the Contractor's License G�
za La.(Chapter 9(commencing with Section 7000)of Division 3 ofthe E
4 o Business and Professions Code)or that he isexaupt therefrom and CITY. PLUMBING PERMIT, , t FEE.
¢ H o (he basis for the alleged exemption.Any violation of Section 7031.5 - STORIES TYPE CONSTR.
au by any applicant lora permit subjects the applicant Ina civil penalty ALTER-DRAIN -WATER'(EA.14,00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE
their Sme compensation,will do the work,and the structure is not 2.00 OCC.GROUP RES.UNITS
intended or offered for Sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds Or improves(hereon,and who does such work FIXTURES-PER TRAP 4.00 50,FT.FLOOR AREA TOTAL ACREAGE
himscl!ar through his own employees.Provided that such improve-
meetsarenotintendedorofferedforsole.If.however•the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have[he burden of proving that he did not build or int- RES IND CON PB Omer
prove 1,aso neeose otf the
INDUSTRIAL WASTE INTER. 20.00
❑ d as owner of the property,he exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed colons Cod to construct the project(Sec.7044•Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The hContractor'sbuild License law does not who
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with u contraetmoo licensed pursuant t0
the COntme(or's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ I am exempt under Sec. BAP C.for this WATER HEATER W/VENT - 4.00
rcuson
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERYCOMPENSATION DECLARATION WATER TREATING EQUIP, 4.00
1 hereby affirm that I have a certificate ofconsent to sell'-insure, ZONING ENG.SITE NO.
or a certificate of Wo 'Compensation Insurance,or a certitied
copy thelISxah.C.). P•C.
Policy No. Company l'
O ❑ !ert itied co is hereby f nlslteJ. FIRE SPRINK ENERGY T]4
Z Z Cert ifed p fjled ith the spection division.
O Applicant RISC.- REFER TO ORD. Y ❑ N '' Y ❑ N❑
CCT CERTIFICATEOF ExEmp'flON 17ROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE AT.U.O.
LLI > COMPE.N5ATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
D Z hundred dollars(S 100)or less.)
L) O Icertify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall of employ any person in any'manner so as to
U beco orkers'Compensation Laws of California.
� y Date PPbc°cotALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: If, he,making this Certificate of E.-
F_ Z emption,you should become subject to the Workeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
0 such provisions or this permit shall be deemed 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
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. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097•Civ.C.). pr
Lender's Name HEATI NG UNIT(OV ER.100,000 B.T.U.)7.50 ELECTRIC O J
Lenders Address
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
ordinances
n correct I agree to comply with all city and county PLUMBING
ordinances and state laws relating c to building ,construction.an,o and BOILER-COMP I3 H.P.or 100,000 B.T.U.) 4.00
hereby authnriee representatives of this city to enter upon the BOILER-COMP (Over 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,j gmw ts, casts and expenses which CONST.TAX
may in an ay ace ue age I a I City in consequence of the PERMIT ISSUANCE 3.00
grand sycrt MECH.CONT. LIC.NO. MECH.
TOTAL. TOTAL
Signature of Applicant/Contractor Datc '
OFFICE COPY