7094 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILo1Nc + APPLICATION & PERMIT
O 5
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL ` 7094
DINNER ✓✓✓✓ PLAN CHECK VALIDATION
"AME n�0 22'tyI/ � /]QTY. ELECTRIC PERMIT FEE
�Uj fHON73 1 ' /
CONT AcrORs OUTLETS
5.00/1.00
NA
V/ Il?✓ uC.No. LIGHTING FIXTURES 5.00/1.00
COIH
NTRACTOR oRs PPLIANCES-RESIDENTIAL 4.00
ADDRESS DRESS (I
X PHONE PANELS 5.00 DATE OF APPLICATION
` ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
0R
ENGINEER
/1/5
� L.C.No. SIGNS TRANS. 3.00
ARCH.OR ERG. m /l. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
EMP.METER OR POLE INS. 15-00
APPLICANTS MOTORS SEE FEE SCH. �^/,f`//
4113 E55 �? / II1 _I Dl
S )III
II UY- r1a03Slile)e- SERVICE CHANGE 10.00
-�0 o LICENSED CON'IRAC'I'ORS DECLARATION
¢ is u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w z w (commencing with Section 7000)of Division 3 of the Business and BL ELECT. PLG. MECH.
r m z Professions Code,and my license is in full force and effect.
z 0 w - License Class-- Lie.Number-
0
umber 0 N -D Date Contractor
• ¢ y E BUILDING PERMIT
Q w ¢ OWNER-BUILDER DECLARATION INFORMATION
1 W ;A r I hereby affirm that I am exempt from the Contractor's License
MISC.- REFER TO ORD
u O< Law for the following reason.(Sec.7031.5.Businessand Professions VALUATION $/FT.
r _ PERMIT ISSUANCE 6.00
]] w Code Any cdyor worepair which structurepermit prior
rtoconsuanc alter,
?Q.¢ ¢ 0O improve,demolish,or repair anystructure,torli priorto its issuance also ELEC.CONTE. LIC.NO. ELEC,
u m u mquircs the d pursuant
for such permit ns file a signed statement that TOTAL PERMIT TO
I".
is licensed purzuam en the provisions of 00 Contractor's License _
1.aw fClmPon9ftrmmencing with Section 7000)of Division3of(lie
- - ¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE L
j¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 1 STORI Sk TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of nrs
ot more than five hundred dollu (4500).): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
R their sole compensation,will do the work,and the structure is not
untended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law docs 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 TOTAL ACREAGE
himself or through his own employees,provided-that such improve-
mcrosotintendedorofferedforsaleIf,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or i;nporrourunt is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will hove the burden off,mv ing that he did not build or in,- RES W D 0 PB Omar
prove for purpose oLmh`). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,um exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct Om project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS CEL NO.
and Professions Code:The Contractor'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 contractor(s)licensed pursuant to
the Contractor,License Law. SEWER-SANITARY-STORM EA.200ft/5.00 TRACT NO. PARCEL NO.
0 lamcxempeunder Sec. .BARO for this WATER HEATER W/VENT 4.00
sun
Owner Date -IL, WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
f
t W60. sCOMPISNS 10. 4C.
ARATION WATER TREATING EQUIP, 4-00
I hereby ate of that I have a certificate ol'con ice,o s c insure,
or a certificate of Workers'Compensation Insuranm,or a certified ZONING ENG.SITE NO.
copy tlmmof(See 3800,Lab.:.).
Policy No. Company
0 0 Certified copy is hereby punished: FIRE SPRINK ENERGY T 24
zp A Cerified copy is filed will, the city inspection division. MISC.- REFER TO ORD. Y ❑ N❑ Y rv❑
( c w CERTIFICATE OF EXEMPT[ON PROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE AC.0 C.
L COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL U (Phis Section need not he completed if the permit is for one TOTAL v❑ N❑ Y❑ NO
Z) Z hundred dollars IS 100)or les.) it
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,I shall not employ any persbn in any manner so as to
U beeolnc subject to the Wnrkcrs'Conlpensation Laws of California.
0 y
Dare-Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} ED NOTICE ro AI•PLICAN'r: If,after making this Certificate of rix.
F Z_ c rp"on,you should become subject In the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must lirthwilh comply with FEE �.�
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC-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/y4ork for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). X/ H EATING UN IT(TO 100,000 B.T.U.) 4.00
Lender's Name �1�e- HEATI NG UNIT(OVER 100,000 B.T.U.)7.50ELECTRIC
Lender's Address
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
intonation is correct. I agree to comply with all city and coolly PLUMBING
ordinances and state laws minting 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 (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,judguents, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in accrue again way accragain said City is consequence of the
gra g of this Per MECH.CONT. LIC.NO. MECH. n
_ TOTAL TOTAL
/>C n tare plicant/ ontmetor Date %
INSPECTOR COPY