6793 (2) �. APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BAI-I POINT PEN ONLY
BUILDING PROJECT IDENTI ION , PERMIT NUMBER
II BDILOIN��G///��� APPLICATION &
"DOBE$/ `0 lo-zim -wed Ave 6793
V`1 BUILDING -ELECTRICAL-PLUMBING-MECHANICA
OWNER'S .. - P AN CHECK VALIDATION
NeiMa
"MeUSQ PRory 7' UTV. ELECTRIC PERMIT FEE /f ^ n e
: NTRACTOR'S (/"C
'NAME 1 t /(,�^ OUTLETS SWITCHES-RECEP 5.00/1.00
5-ertJ0k C LIC.3 /�D7.7 ' LIGHTING FIXTURES 5.00/1.00
ADDRESSNTRACoR's � PPLIANCES-RESIDENTIAL 4.00
CO {{��
C r9dPHONE ^0 PANELS 5.00 DATE OF APPLICATION
OR
, SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ARCLI.OR
ADDRESS ENG SPEOIALCIRCUIT 5,00 . PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
ADDRES �
S MOTORS SEE FEE SCH. �I �
ADDRESS
SERVICE CHANGE 10.00
o¢z
Foo LICENSED CONTRACTORS DECLARATIONS
`Q v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DTE '
w D m (commencing with Section 7000)of Division io(the business and B g6T1 MECH.
r w z Professions Cad a d license is in full for of -c['s LI�J 4
z D w License I:- Lie Number '�!
m Date �ConlraUor • - ..
¢ a OWNER-BUILDERDECLARATION
z a a" MISC.- , REFER TO ORD INFORM
E:
g¢m I hereby affirm that I am exempt from the Contractor's License _
LL o a Law for the following reason.(Sea 703 L5,Businessand Professions
Y LUA I N 1/FT.
L - Code:An cit or count which re PERMIT ISSUANCE 6.00 operti ID
Any y y r u tune permit t oconsuance,also
¢¢¢p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. 0
ELEC.
i w esu requires the applicant for such permit to file a signed statement that TOTAL PER T,TO
he is licensed pursuant en the with Suns of the )ontmdor s License rj i
5 z a
Law.(Chapterand
Pro(commencingsionsde)or Section is exempt
t Division 3o the
s 4 o Busness and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
IF I-m , the basis for the alleged exemption.Any violation of Section 7031.5 STORIES YP CONSTR.
n3 -
by any applicant for a permit subjects the applicant macivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(1500).):
O' I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP REE.UNITS
their sole compensation,will do the work,and the structure is 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 SD.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve-
oments rimprvemenintended oroffered
onefor year
If,
complevegt the one, GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS' EASYSTEM--OVER 4 IEA.) 1.00 BUILDING USE
prove
builder f will have the burden of proving that he did not build or im - .- ^
profor purpose of sale.). R IND CON Pe Omer- INDUSTRIALWASTE INTER. 20.00 11 El El El
❑ I,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 Code:The Contractor's Licips.Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
commas for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.,200Tt/5.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&.P.C.for this WATER HEATER W/VE . 4,00
..,on
WATER
Date WATER SYSTEM -4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPF-NSA1 ION DECLARATION WATER TREATING E4 4
4.00
1 hereby affirm that 1 have a cartificate orconsent toself-inmm,
r or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy therer(Sce.3500,Led,C 6 1 0�
policy No. Company���1W���r1���I-///LLL
,0 Certified copy is hereby furnishedie"- G' FIREEPRINK ENERGYT-24
Z Z Certified copy it filed .with the pity mspec o
O n ielo¢ MISC.- S REFER TO ORD.
A phcam - - Y N Y N
may ' CERTIFICATE OF EXP-MPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOOZONE A.L.U.C.
Lu COMPENSATION INSURANCE PLG.CONTR: LIC.NO. PLG.
Z (This section need not be completed if the permWis for one TOTAL Y❑ ND Y N❑
hundred dollars 1$100)or less.)
L) O I certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,1 shall not employ any person in any manner so as to
V hecome s e t a the Workers'Cory�jsns--aaUDnn Lyyyrf Col�ornia.
Date Applicant /J<I/.aE /Z✓�/��'/•�-'
BUILDING
a ALTER OR ADD TO MECH. 4.00
} W NOTI T A PLICANT: If,n er ma ing flus etli ca a x-
♦- Z eniption,you should become subject m the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of'the•Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTR UCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10MOC.F.M.) 5.00 SEISMIC FEE Z
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(Sea MICROFILM
3097,Civ.C.). 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 I have read this application and state that the above VENTILATION FAN ISINGLE) 3.00
information is correct, I agree to comply with all city and county PLUMBING
.� ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.Dr 100,000 B.T.U.) 4.00
hereby-authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)EEE FEE ECH.
above-mentioned property for inspection'purposes. 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 way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
grant in this permit._ _ r MECH:CONT. LIC.NO. MECH.
aant//I l TOTAL ,
Signatu7e of AppllcanljOd
Contractor la
OFFICE COPY