5866 (2) T APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION
PERMIT NUMBER
DDAPPLICATION & PERMIT
A -
DDRESSRESS 10400 Rid eview Court '6
- BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 586
OWNER'S PLAN CHECK VALIDATION
NAME OVExf PHONE QTY. ELECTRIC PERMIT FEE
C R. Nd/� ,
1 CONTRACTOR'S
NAME 187293 C-16 UTLETS-SWITCHES-RECEP 5.00/1.00 ,
Viking Fire P{Qtpction ILIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
AOOR Ess
969 IndustrialRH$Rad, Ste. PANELS 5.00 DATEOF APPLICATION
ARCHITECT San Carlos, AA. SIGNS 6.QQ PLAN CHECK FEE P.C.NO.
OR
ENGINEER
' uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. v C WO SPECIAL CIRCUIT .
SQQ PERMIT VALIDATION
ADDRESS ng & Associates, I
2901 Gordo z EMP.METER OR POLE INS. 15.00
APPLIANT'S 95051 MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 /9
wo o LICENSED CONTRACTORS DECLARATION 1
v U I hereby affirm That I am licensed under provisions of Chapter 9 ISSUANCE DATE
y rt w (conuneman,with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F y 2 Professions Codyy,, n�yly license is in full force and effect. ❑ ❑ ❑ ❑
' 0. - License Class_Sa-(n Lie.Number 1877Qo�.�o
0 w Date Contractor
a e f � -0 BUILDING PERMIT,
Ic w a OWNER-BUILDER DECLARATION INFORMATION
A oa 0 MISC- REFER TO ORD
X LL N 1 hereby affirm that 1 am exempt from the Contractor's License VALUATION SIFT-
a_
0< Law for the following reason.(See.7031.5.Bn6ectsand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
- 0 ac requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A w m m he is licensed pursuant m the provisions of the Contractor's License '
FZ > Law(Chapter 9(commencing with Section 7000)of Division 3 of the
< Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES. TYPE CONSTH.
t R _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(8500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compenvtion,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such onProve-
cleIsare not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 4.00
improvement is sold within one year of completion,the owner- .GAS-EA.SYSTEM OVER 4 IEA) 1.00 euILDING u5E
tiodder will have the burden of proving that he did not build or im- - . RES ' IND CON PB Ohner
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
O 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.
,aProfessions Codr.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
contractsforcontracs)li«nsxd pursuant to
Ire Cs fo such
projects
roje License
Law. mr( SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sea. ,B.&I•.C.for this WATER HEATER W/VENT 4.00
reason
Owner Data WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAT'ION D17CLARA'I ION WATER TREATING EQUIP. 4.00
1 tremby aflinn ilial I have a Certificate of Camu:nl to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lob.C.).
Policy No. --Company-
0
'ompanyO R Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
0 Applicant Y❑ N❑ Y ❑ N❑
M CER1'IFICA'1'17 OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.0
W > C041:NSA'1'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
EL O O'his section recd not be completed if the Recruit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z) Z hundred dollars($100)or leu.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
ad Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} y NOTICE TO APPLICANT: If,after making this Certificate of Ex-
�, Z emption,you should become subject to the Workers'Compensation APPLIANCE p 4.00 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 10MOC.F.M.) 3.00 8.95
�' CONS'TRUCIFION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby affirm tint there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
tie performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.CJ:
s Lender's Name
Lender's AddreHEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
ss
I certily that I have read this application andscam that the above VENTILATION FAN (SINGLE) 3.00
infonnatibn'is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction,and BOILER-COMP(3H.P.or100,000B.T.U.) 4.00
hereby amhorize representatives of this City to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-memioned property for inspection purposes.
j ,(We)r egree to save, indenmify and keep harmless the City of MISC.- REFER TO ORD.
Cupertinoagainst liabilities,judgments, costs and expanses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in con emence of the
gmntipg of this pernnt. MECH.CONT. LIC.NO. MECH.
1 B-22-84 TOTAL TOTAL
Signatureof Applicant/Contractor Datc 6
T •i INSPECTOR COPY