11089 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON - PERMIT NUMBER
RUIIQIN , APPLICATION & PERMIT , 11089
ADORESs - -
g. BUILDING - ELECTRICAL_PLUMBING-MECHANICAL
OwnER'S� PLAN CHECK VALIDATION r. NAME G o S - /GG D�7.` - OTV ELECTRIC PERMIT FEE
HIS
Ti coNTRacro N _ / - OUTLETS-SWITCHES-RECEP 10.00/1.00
uc.rvo.y a ILIGHTING FIXTURES- 10.00/1.00
CONTRA Rs
ADDRESS APPLIANCES.RESIDENTIAL I 4.00
r
PHONE 8?,'� - PANELS 10.00 DATE OF APPLICATION
ARCHrrecr PANELS (OVER 200 AMP) 20.00 PLANCHECK FEE P.C.NO.
oR
ENGINEER -
LIC.NO SIGNS TRANS. 3.00
ARCH.OR ENG, PERMIT A I�Pf
ADDRESS SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00 - p _
APPLICANTS MOTORS SEE FEE SCH. MAR 2 ('
DDRESs '
IS CHANGE 20.00 /f+ /r 198G
o o LICENSED CONTRACTORS DEC ARATION City Of 1aOpQrtino
¢L, I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Na N' (commencing with:Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F 0 z Professions Code,and my license is in full force and effect. El ❑ El0 i w D License Class Lic.Number
Dale Commctar
¢ y BUILDING P RMIT
¢ ¢w OWNER-BUILDER DECLARATION INFORM ION
n 0 y - MISC.- REFER TO ORD
X ;LL H 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
� ¢0 < Law forthe following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE, 10.00
Ew0f Code:Anycity orcounty which requires a permit to construct,alter, ELEC.CONTR. LIC.NO.
¢ ¢ ¢ o improve,demolish,or repair any,structure,prionto its issuance,also - ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
d L,
, .u.
he is licensed pursuant to the provisions of the Contractor's License
H z a
Law(Chapter 9(commencingwith Section 7000)of Division 3 of The
F 4 D Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢F$ the basis for the alleged exemption,Any violation of5eclion 7031.5 _ STO IES VPE CONSTR.
by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00 RI not more than five hundred dollars(55001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.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. 5.00 -
Code:The Contractor's License Law does not apply to an owner of
property who budds or Improves thereon,and who does soch work FIXTURES-PER TRAP 5.00 56 FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedor.offered for sale,If,however,the funding GAS-EA.SYSTEM-1 INC.
0,
6.00
or improvement is sold'withm'iane year of completion,the owner- - GAS-EASYSTEM, 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- . RES IND' D PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30,00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
• licensed contractors to constmct,ihe project(Sec.7044,Business LAWN SPRINKLERS-'1 INC 5 V.8. 6.00ASSESSO S PARCEL 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-OV ER 5(EA.) 1,00
COntr3Cta I'ar such projects with a contractorfs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10,00
the Contractors License Law. TRACT NO, PARCEL NO.
❑ I am exempt under Sec. ' ,B.&P.C.far this WATER HEATER W/VENT 6.00 -
reason
Owner - Late WATER SYSTEM - 5.00 ACC.DATE Acc,FILE No.
WOR'ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
t� 1 hereby affirm that I have a certificate ofconsent to self-insure,
\s1Y� or a certificate of W...Urs'Compensation Insurance,or u cotlifiecl ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.0). - -
Policy NO. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z 2 rtifie) cop fled with t Li as lion vision.
p Applican - 'i.- _�- MISC.- REFER TO ORD. .y❑ N❑, y ❑ N❑
CC r2 PERMIT ISSUANCE 10.00 a. FLOOD ZONE A.L.U.C.
Ui Iil2Tl FICCOIi MOP EXEMPICOMPENSATION
FROM WORKERS' -
W - COMPENSATION INSURANCIi PLG.CONTR. LIC.NO. PLG.
CL O (This sedion need not be completed if the permit is fur one TOTAL V❑ N❑ Y❑ N❑
Z) 2 hundred dollars(S 100)or less.) -
U O 1 certify that in the pciformi nce of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
ILL H mit is issued,I shall not employ any person in any nwnner so as to ,
U become subject to the Workers'Compensation laws of California.-
' y Date - Applicant " ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
L._ ? emption,you should become subject to the Workers'Compensation APPLIANCE 5,00 PLAN CHECK
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 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000CF.M.) 6.00 SEISMIC FEE
I hereby affirm that there is S construction lending agency I'or EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.Q). '
Lender's Name -
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
T -
Icertify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and comfy '
PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city lo.cater upon the
above-mentioned property for inspection purposes. BOILER-COMP over 100,000 BTUI SEE EEE SCH. 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
w
may in any ay'accrue against said City in consequence of the PERMIT ISSUANCE 10.00
V / granting iia permit MECH.CONT. LIC.N0. MECH.
�a � �/S� TOTAL TOTAL
1r�
Signature of Ap icant/Contractor Uute�
OFFICE COPY .