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11712APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU I LDI NG PROJECT I DENTI FICATI ON APPLICATION & PERMIT -ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 11712 BUILDING (7%%'� �� L�BUILDING OWNER'S NAME {- `/' PHONE QTY. ELECTRIC PERMIT FEE PLAN LHECK VALIDATION ' ' CONTRACTOflS - -7 NAME �' •_� b /-j/ Vit. 1-•L-I�r uc: No. -r UTLETS -SWITCHES-RECEP 10.00/1.00 '0 LIGHTING FIXTURES 10.00/1.00 u .ONTRAf$CTow,l AD BF/ / PPLIANCES-RESIDENTIAL 4.00 PANELS 10.00 ` O PHONE DATE OF APPLICATION ARCJmTEC/UT/-PANELS OP ENGINEER LIC. NO. (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. N0. SIGNS TRANS. 3.00 ARCH, OR ENG. ADDRESS ZIP SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ^ ) - IVIA�I","14-� 4- (u � TEMP. METER OR POLE INS. 20.00 APPLICANT'S ADDRESS MOTORS SEE FEE SCH. i SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION r'' J 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cod an license is in full ford r e License Cl�- sLic.e is Number Dale Contractor ISSUANCE DATE -TL.G.7 ❑ ELECT. 1 PLG. MECH. ❑ ❑ t�pe�n° ``qty BUILDING PERMITINFORMATION OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and io the basis for the alleged exemption. Any violation of Section7031.5 MISC. - REFER TO ORD VALUATION - PERMIT ISSUANCE 10.00 ELEL, CONTR. LIC. NO' - ELEC. d -p TOTAL PERMIT TO QTV. PLUMBING PERMIT FEE STORIES TYPE CONSTR. ALTER-DRAIN-WATER(EA.) 5.00 by any applicant for a permit subjects the applicant ma civil penalty afoot more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS , DRAINS -FLOOR, ROOF, AREA, COND. 5.00 Code; The Conlmetor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work F IXTUR ES - PER TRAP 5.00 SO. FT. PUMP AREA 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.SVSTEM-11NC.40UTLETS 8.00 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- proveforpurposeofsale.). O 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 BUILDING USE RES IND CON PB Gore, ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 - LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. contracts for such projects with a contractors) licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200h/10.00 TRACT NO. PARCEL NO. ❑ lam exempt under Sec.-, BAP.C. for this WATER HEATER W/VENT 6.00 reason Owner Date - WATER SYSTEM 5.00 ACC. DATE ACC. FILE N0. 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 Wor ers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy Ther�P�ffI(So C.).rs ,, ) A ^ ,f R Policy NQ„ =_ ` 1 `�`7�I y fished. ❑ Certified copy is hereby furnished. CertiOcd L rs Oled w'th the city jp c�fS2.n division. A plicanl��' 1^ b• FIRE SPRINK Y N ❑ ❑ ENERGY T24 Y N ❑ ❑ MISC. - REFER TO ORD. CERTIFICATE, OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C. PLG.CONTR. 'LIC. NO. PLG. TOTAL COMPENSATION INSURANCE (This section need not be completed if the permit is for one y❑ N❑ -Y❑ N❑ QTV. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars IS 100) or less.) I certify that in the performance of the work for which this per- mit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. - Date Applicant NOTICE TO APPLICAN'C If, after making this Certificate of Ex- emption, you Should become subject to the Workeri Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING I ALTER OR ADD TO MECH. 5.00 JAPPLIANCE 5.00 PLAN CHECK FEE AIR HANDLING UNIT (TO 10J=C.F.M.) 4.00 AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is ivaned (Sec. 3097, s Na ). Lender's Name HEATING UNIT (TO 100,000 B.T.U.) 6.00 HEATI NG UN IT (OV ER 100,000 B.T.U.) 9.50 ELECTRIC Q � Lender's Address VENTILATION FAN (SINGLE) 4.00 PLUMBING 1 certify that I have read this application and slate that the above information is correct. 1 agree to comply with all city and county ordinances and state laws relating. to building construction, and BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL hereby authorize representatives of this city to enter upon the above -me 'oned pro erty for inspection Pur uses. (We) g e t save, i crucify anJ ke harml the City of Cupertin gain Bebiliti , judgments, c s and penses which may in y wa ' st said Cit in co uenee f the I 's p r D MISC. - REFER TO ORD. CONST. TAX PERMIT ISSUANCE 10.00 MECH. CONT. LIC. N0. MECH. TOTAL TOTAL Sig to fApplic o raclor Date OFFICE COPY