10981 _ PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
'✓ BUILDING PROJ IDENTIFICATION PERMIT NUMBER
DiLDI APPLICATION & PERMIT
•
MOR �� r BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 10981
OW ER'S PLAN CHECK VALIDATION
III • NAME QTY. ELECTRIC PERMIT FEE
PHONE
DO GTOR UTLETS-SWITCHES-RECEP 10.00/1.00
N
'LIc.No. LIGHTING FIXTURES 10.00/1.00
.O T 's APPLIANCES-RESIDENTIAL 4.00
ao
DRO PANELS 10.00 DATE OF APPLICATION
RCHrcEcr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00 In A
ARCH.OR ENG. SOD 'IDATION
ADDRESS SPECIAL CIRCUIT ,
ZIP EMP.METER OR POLE INS. 20.00 MAR 2 8 1986
app 1 ANT'S MOTORS SEE FEE SCH.
A 5
SERVICECHANGE 20.00 City ofCoertino
w
02 LICENSED CONTRACTORS DECLARATION
a v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
Ga w (commencing with Section 7000)of Division 3 of lite Business au BLDG. ELECT. PLG. H.
w z Professions Codd��SSu� license is in full line
Z 0 m - License Class Lic.Number ❑ ❑ ❑
9 w Eon Dale Contractor
Q Y a ¢ OWNER-BUILDER DECLA A I BUILDING PERMIT
a o d u MISC.- REFER TO ORD INFORMATION
of
X 0 u m I hereby affirm tuns[I ant exempt from the Contractor's License VALUATION SIFT.
F a.0j Law for the following reason.(Sec.7031.5,Businessund Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a Derail m construct,alter,
M Q FO m ,p
improve,deolish,or repair any structure, to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
oc - 0 LL requires the applicant for such permit to file a signed s'lutement that TOTAL ERM TO
a w m wt he is licensed pursuant to the provisions of the Contractor's License _
F z a
Law(Chapter 9(commencing with Section 7000)o'Division 3 of the
i 0 Rosiness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
M s. the basis for the alleged exemption.Any violation of Section 7031.5 - STORIE TYPE CONSTR.
i ;$ by any applicatfor a permit subjects the applicant los civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more that five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not __UCC GROUP RES.UNITS
intended Cr offered for sale (Sue. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
• property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve GAS-EA.SVSTEM-11NC.40UTLET$ 6.00
mems arc not intended or offered for sale.If,however,the building
or imp-S uenl is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im R S IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 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. 6.00 ASSESSORS PARCEL NO.
and Professions Code;Tire Contractor's License Law dues not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contradtf9 olicensed pursuantto
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Co
❑ I am exempt under Sec..,11&P.C.for this WATER HEATER W/VENT 6.00 -
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
WORKERS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 5,00
1 hereby affirm that I have u certificate ofconsent to self-insure, ZONING
or a certificate of r Compensation Imer cc,or a c tilled TING.SITE NO.
copy there g-�'n C.).
Policy N,)_ WC s s nY
O Certified copy a he ami a FIRE SPRINK ENERGY T-24
Z Z ertified cop D w' ire y pedion division. MISC.- REFER TO ORD.
0 APP nl Y❑ N❑ Y ❑ N❑
tn - V--
CERTIFICATICOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00
F LOGO ZONE A.L.U.C.
LU > COMPENSAT ION INSURANCE PLG.CONTR. LIC.NO. PLG.
d a (This section need not be completed if the permit is for one TOTAL Y❑ N❑ I Y❑ N❑
Z hundred dollars IS 100)or less
U 0 1 certify that in the performance of the work for which this per, QTY. MECHANICAL PERMIT,, FEE FEE SUMMARY
LL P mit is issued,1 shall not employ any person in any manner so as to - -
O become subject to the Workers'Compensation Laws of California.
y Date Applicant, ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE 1'0 APPLICANT: 11,after making this Certificate of LS-
I F Z emption,you should hero.,subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you nmst futlhwith comply with FEE
U such provisions or this permit Shull be deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10)"C.F.M.) 6.00 ISMIC FEE
I Imreby affirm Thal there is a construction lending ugenry for EXHAUST HOOD (WITH DUCT) 5.00
the performance of tire work for which this permit is issued(Sec. X
HEATING UNIT(TO 100,000 B.T.U.) 8.00 ICROFILM
3097,Civ.C.).
Lender's Name HEATI NO UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and corour PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
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, inde y and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against ilitie lir menus, costs and expenses which ST.TAX
maY i ny w true n, I said City in consequence of the PERMIT SUANCE 10.00
gr' ng Iif mIL /.' M H.CONT. LIC.NO. MECH.
� TOTAL s TOTAL
rs l res 1/Contractor Date
OFFICE COPY