9062 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATIO APPLICATION St PERMIT PERMITNUMBER
BVILVING
DDnES
s BUILDING - ELECTRICAL-PLUMBING -MECHANICAL -
9062
OWNEn'S
rvAME PLAN CHECK VALIDATION
TY. ELECTRIC PERMIT FEE
PHONE ?3
C Across UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESSTORS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT
on PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE I P.C.NO.
ENGINEER
LIC.No. ISIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00
ADDRESS PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 MAY 1 Z 1986
ADDRESS T s MOTORS
SEE FEE SCH.
SERVICE CHANGE 20.00 City of Cuperfino
02
Fo0o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u v I hereby affirm that I am licensed under Provisions of Chapter 9
w a w (commencing with Section 7000)of Division 3 of the Business and ISSUANCE ATE
H H 2 Professions Code,and my license is in full force and effect. BLDG. ELECT. LG. MECH.
Z i w W License Class Lic.Number. ❑ ❑ E)m r Date Contractor
Q T
a w a OWNER-BUILDER DECLARATION BUILDING RMIT
U INFORM TION
I'xu ;' H I hereby affirm that I am exempt from Ote Contractors License MISC.- REFER TO ORD
FLLof Law for the following reason.(Sec.7031.5,Businessend Professions PERMIT ISSUANCE VALUATION $/FT,
w� Code:Any city or county which requiresa permit to construct.alter, 10.00
Q ca improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
ce requires the applicant for such Permit to file a signed statement Out ELEC.
u w m u TOTAL MON
IT TO
he is licensed pursuant to the Provisions of the Contractor's License
H z a
Law(Chaplet 9(commencingwith Section 7000)of Division 3 oflhe
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
re H m the basis for the alleged exemption.Any violation of Section 7031.5 YPE CONSTR.
d3 � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN of not more than five hundred dollars(850H.): (EA.) 5.00
❑ 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 RES.UNITS
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 builds or improves tlmrcon,and who does such work FIXTURES-PER TRAP 5.00 FLOOR TOTAL ACREAGE
• himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-i 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 im. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 G USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ON PB Omer❑ I,as owner of the property.am exclusively contracting with ❑ ❑licensed contractors to construct the prject(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00and Professions Code:The Contructois Li.ense Law does not apply PARCEL NO.
to an owner of property who builds or improves tlmrcon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such Projects with a contractors)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ exempt under Sec. ,B.&P.C.for fills WgTER HEATER W/VENT
Owner6.00
Date WATER SYSTEM 5,0
ACG DATE ACG FILE NO.
WORKI?RS'COMPIiNSn'I'ION UECLA RATION WATER TREATING EOOIP. 5.00
1 hereby affirm that I have a certificate of....sent to self insure,
or a certificate of Workers Compensation Insurance,ora certified ZONING ENG.SITE NO.
copy thereof I Sec.3800,Lab.C.l,
Policy No. Company
U 0 Certified copy is hereby furnished.
Z Z ❑ Certified copy is filed with the city inspection division. FIRESPRINK EN EDGY T24
F O Applicant MISC.- REFER TO ORD. y N� V N�
Q- h CERTIFICATE 017 EXEVIP1'ION PROM WORK Ii RS' PERMIT ISSUANCE 10.00
LU > COhIPENSA1'ION INSURANCE PLG.CONTR. FLOOD ZONE A.LU.C.
d ❑ LIC.NO. PLG.
Z (This sellarn need not be completed if the permit is for one TOTAL V N� V 0 NE]
U O hundreddollars 151001 peless.)
I certify that h the pmformanda of the work for which this Per.
0 f in
is issued,1 shall not employ any Person in any manner so as m CITY. MECHANICAL PERMIT FEE FEE SUMMARY
Q w become subject to the Workers'Compensation Laws of California.
y Date ICANI:ot ALTER OR ADD TO MECH. BUILDING
} to NOTICE TO API'LICAN'1': IL alter making Wis Cert ilicua of Ex- 5.00
Z emption,you should become subject to the Workers'Compensation APPLIANCE
provisions of the Labor Code, you must forthwith comply with 5.00 PLAN CHECK
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10000C,F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the Performance of the work for which this permit is issued(Sec.
3097,Civ.CJ. MICROFILM
HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEAT[NG UN IT(OV ER 100,000 B.T.U.19.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4
• Information .00
correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction. and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
herebyy authorize representatives of this city to enter upon the
aboJemenlioned Property for inspection purposes. BOILER-COMP IDvar 100,000 BTU)SEE FEE SCH. MECHANICAL
e) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
C ertino against liruabilities,judgments, costs and expenses whi7ch
y in any way acce against said City in consequence of the PERMIT ISSUANCE 10.00 CONST.TAX
ao 6 of thisP ermiL MECH.CONT. LIC.NO.
MECH.
l r S=iZ TOTAL
Date TOTAL
Signature of ApPbcant/Contractor
OFFICE COPY