7094 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATION ICATION & PERMIT PERMIT NUMBER
APPL
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 7094
. OwNER'S _ i�Rn. 4 �1 .�'�,5. '�# - -� PLAN CHECK VALIDATION
UPSP LyIn'TY.L ELECTRIC PERMIT FEE•
��2w000 r) PHON�3 I �I I
X-7 47Y �Z-.�1
CONT ACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
;r A /`•Vicom✓ LIC NO. LIGHTING FIXTURES 5.00/1.00 JAN 15
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS I, CR of Cu ertioQ
`. PHONE PANELS 5.00 DATED APPLICA ON
ARCHITECT SIGNS 6,00 PLAN CHECK FEE P.C.NO.
ENGINEER
n S cv LIC.NO. SIGNS TRANS. 3.00
ARCH.OR NG. I PERMIT VALIDATION
,/,J -/ /YI ! SPECIAL CIRCUIT 5,00
A oR \ ,M"'idlFfi-e�(J 3 EMP.METER OR POLE INS. 15.00
APPLICANTS I �'// MOTORS SEE FEE SCH.
ADDIR s ���� ZZ /
i t3 au)c /�dwSfv��e SERVICE CHANGE 10.00 1IlIs
o o LICENSED CONTRACTORS DECLARATION
a v E, I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w G m (commencing with Section 7000)of Division 3 of the Business and BL G. ELECT. PLG. MECH.
E.w z Professions Code,and my license is in full force and effect. El El 11o License ClassLia Number
m F Date Contactor
a o n`a OWNER-BUILDER DECLARATION f�i,v.,,,.SU11ISQRMABRM ,
X gLL r 1 hereby allirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
F u o j Law fm the following reason.(Sec.]031.5.Businessand Professions PERMIT ISSUANCE VALUATION $)FT.
Code:Any city or county which requires a permit to construct,alter, 6'�
F m E ELEC.CONTE. LIC.NO. I )
re ¢ ¢O Improve,demolish.or repair any structure,prior to its issuance,also ELEC.
i w m u requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License TOTAL PERMIT TO
H i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe xwii;"i+.f^' .7%". qg; u.`�Fx- i-RI{s% '•'•. ,.fi%. - /I
a Business and Professions Code)or That he is exempt Theo from and QTl/i• SPfiUMBINO FfiRMIT E .x`aa9. Q i �. I l.li��
s o the basis for the alleged exemption.Any violation of Section STORI S TYPE CONSTR.
s- ;c.! by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
Ed not more than five hundred dollars C15000.).
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure a not
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 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
ments are not intended oroffered for Sale.If,however.the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 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 the burden of proving that he did not build or ins. RES IND 0 PB Other
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 C3❑ I,as owner Of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5,00 ASSESSORS EL NO.
and Professions Code:The Comactor'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 cratra,lm t)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Ow"" Date '- WATER SYSTEM 4.00 ACC.GATE ACC.FILE NO.
(CO
O 'R OMPE O CLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to sel&insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab C.1.
Policy No. Company
O ❑ Certified copy is hereby furnished.
FIRE BPRINK ENERGY T 2
Z 2 ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant V E] No V [:] NC]
CC T CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG, v N� v rv�
� Z TOTAL(TI Is section need not be completed if the permit is for one
hundred dollars 141001 or less.) Pa?a'e , v S11vX+ .y„(p+ ' 'z, ,a aMCI
M*
U O I certify that h the performance of the work for which this per. Qom. MECHANI AYPERMIT Y Wlwta __
LL F mit is issued,I shall not employ any person in any manner sO as toIonF y �.g ,Rhc,- ` r L b `
O w become subject to the Workers'Compensation Laws Of California. C - J
Date Applicant BUILDING
a pp ALTER OR ADD TO MECH. 4.00
} zo NOIICE TO APPLICANT. If,after making this Certificate of Ex
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK ff�
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions Or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10JIMC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00GEM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performanceof t"he/Fork for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). v /L 1�P HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name N
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.5O ELECTRIC
I 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 BOILER-COMP(3 H.P.os'100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to budding construction, and
hereby authorize representatives Of this city li enter upon the BOILER-COMP I Over 100,000 STUI SEE FEE BCH. 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 andexpenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue again said City in consequence of the
Par
ra g of this pe MECH.CONT. LIC.NO. MECH.
TOTAL
'�
gnature I pplicant counselor Date
OFFICE COPY