10186 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BGILDING APPLICATION & PERMIT
/DOREES 10186
O � BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'$
NAME PLAN CHECK VALIDATION
- QTY. ELECTRIC PERMIT FEE
C• PHONE
lie NAm.AOTORs UTLETS-SWITCHES-RECEP 10.00/1,00
um IC.No' LIGHTING FIXTURES '10.00/1.00
TRAC
CONTORS t�a cles% APPLIANCES-RESIDENTIAL 4.00
CONTRACTORS
,PHONE \� PANELS 10.00 DATE OF APPLICATION
ogcHRECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIc.No. SIGNS TRANS. 3.00 PAIL)
ADDRESS ENG. SPECIALCIRCUIT 5.00 DEC? ALIDATION
xlv EMP.METER OR POLE INS. 20.00 CL 2 G 1985
aoo essTE MOTORS SEE FEE SCH,
SERVICE CHANGE 20.00 C)ry of Caoertino
09 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Q O u I hereby affirm that I am licensed under provisions of Chapter 9
2 u ISSUANCE DATE
N ¢ n (commencing with Section 7000)of Division 3 of the Business and LG.
r H z Professions Code, ,itI icense is in full to •a t. MECH.
❑ ❑BLDG. ELECT. 13z o m- Licen ass Lic.Numtw
Nw Data - Contractor
¢ Y ` Yr N BUILDING PERMIT
¢ a w a OWNER-BUILDBR DL'CLARA ION
s °A 1 _ MISC.- REFER TO ORD INFORMATION
w ; H 1 hereby affirm that I am exempt from the Contractors License VALUATION $/FT.
a- o¢ Law for the following reason.(Sec.7031.5,Businessand Professions
- PERMIT ISSUANCE 10.00
w i Code:Any city or county which requiresa permit to construct.alter,
I[ 2 ¢ O improve,demolish,or repair any structure,prior m its.issuance,also ELEC.CONTR. LIC.NO. ELEC.
¢ requires the applicant for such permit to file a signed statement that TOTAL
e w m a he is licensed pursuant to the provisions of the Contractor's License ERMIT TO
H z Q Law(Chapter 9(commencing with Section 7000)of Division 3 of the
f z c Business and professions Code)or that be is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H$ the basis for the alleged eiemplion.Any violation of Section 7031.5 STO IES TYPE CONSTR.
i3 � by any applicant for a permit Subjects the applicant ton civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than 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 01e work,and the stone re is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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 SQ.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments arc not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or am- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of Sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PS Omer
❑ 1,as owner of the properly,am exclusively contracting with
licensed contractors to construct the Project(Sec. 7044,BusinessLAWN SPRINKLERS-1 1NO5 V.B. 600 ASSESSOR S PARCEL NO.
and Professions Code:The Contractor's License Law docs 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 SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec..,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'
a nCompensation Insurance. a cetlifjetl ZONING ENG.SITE NO.
copy thencoffse
Policy No. Company
OCertified c is hereby furnished.
Z 2 -Cern c y u II the cit inspec 'o d' inion. FIRE SPANK ENERGY T-24
i
Applicant MISC.- REFE ORD. Y❑ N o Y❑ N[]
~ t� PERMIT ISSUANCE 10.00
Lu - CERTIFICATE EXEMPTION INS FROMWORKERS' O• FLOOD ZONE A.L.U.C.
W � COMPENSATION INSURANCE PLG.CONTR. LIC,NO. PLG
IL O (This section need not be Completed if the permit is for one g�)L V 11 TOTAL\ .00 Y❑ NE3 Y ❑ N[:]'
::) Z hundred dollars(SI00)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mil is issued, I shall not employ any person in any nmnner. na rl
become subject to the Workers'Compensation Laws of California.
0 y Date ApplicantBUILDING
>_ W NOTICL'e TO AITLICANT: If,after making this Certificate of fix- ALTER OR ADD TO MECH. 5.00
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with U FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of tiro work for which this permit is issued(Sec. MICROFILM
3097,Ci,C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify shut l lmveread this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county OILER•COMP(3 H.P.Or 100PLUMBING
ordinances and state laws relating'to building construction, and ,000 B.T.U.) 6.00
hereby authorize representatives of this city to enteB
r 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,judgments, costs and expenses which CONST.TAX
may in any ay ,CC ainst said City in consequence of the PERMIT ISSUANCE 10.00
granting Is perm MECH.CONT. LIC.NO, MECH.
TOTAL TOTAL \
Signature of Applicant/ omraclor Dale
OFFICE COPY