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10946APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY -- IBU I LDING PROJECT I DENT] FICATI ON APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PER MIT NUMBER 1 0946 BUILDING ADDRESS as as u r OWNER'S PLAN CHECK VALIDATION NAME HON JJ' DTV. ELECTRIC PERMIT FEE OTDR's NAME NAME OUTLETS -SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 UM LIc.N �J9 CONTRACTOR S9 A. ~qxe 0 '.�9G� OICHESSNTRAC PPLIANCES-RESIDENTIAL 4.00 PANELS 10.00 Q1,1-0041PPHONE YyPZO 443��p p DATE OF APPLICATION OR RcwTEci O ENGINEER LIC. No, PANELS (OVER 200 AMP) 20.00 PLANCHECKFEE P.C.NO. ISIGNS TRANS. 3.00 ARCH. SS ENG. 5.00 PERMIT PERMIT VALIDATION TEMP. METER OR POLE INS. 20.00 zip n n / [ APPLICANTS ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION�r - 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Codee it y license is in full form d.rtfe� Licens•Class Lic. Number 71FV ISS ANCE.ATE BLDG. ELECT. I PLG. MECH. Dale Contractor NCJ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following mason. (Sec. 7031.5, Businessand Professions Code: Any city or county which requiresa permit toconstrum 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 BUILDING PER T INFORMATIONVALUATION MISC.- REFER TO ORD PERMIT ISSUANCE 10.00 $/FT. ELEC. CONTR. LIC. NO. ELEC. TOTAL PERMIT TO CITY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant too civil penalty of not more than five hundred dollars ($5001.): ALTER -DRAIN -WATER IEA.) 5.00 ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not BACK F LOW PROTECT. DEVICE 4,00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00 intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of properly who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- mentsare not intended oroffered for sale. If, however, the building or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build o r im- prove for purpose of sale.).INDSTRSTE O 1, as owner of the property, am exclusively contracting with FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTALACREAGE GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00 - d, - . .. GAS EASYSTEM -OVER 4 IEA) 200 BUILDING USE RES IND CON PB Omer ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WA0 INTER. 30.0 licensed contractors to construct the project (Sea 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 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 contractor(s) licensed pursuant to the Contractors License Law. SEWER -SANITARY -STORM 10.00 TRACT NO. PARCEL NO. O lam exempt under Sec.-, B.&P,C. for this mason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM6b01 ACC. DATE ACC. FILE NO. WATER TREATING EOU P. 5.00 WORKERS'COMPENSAT ION DECLARATION 1 hereby affirm that I have a certificate at consent to self -insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab.C.). Policy No. Company STif?r IQGt!/d Q, IZONING / d/e / ENG, SITE NO. \ v ❑ Cent ilied Copy is hereby furnished. iQ Certif�ied�copy Is BIy,�I with t ciy inspe 9iu ivisum App /." FIRE SPRINK Y ❑ N❑ ENERGY T-24 Y ❑ N❑ MISC. - - REFER TO ORD. CERTIFICATE OF 17XEMPI'ION FROM WORKERS' PERMIT ISSUANCE 10.00 /00, FLOOD ZONE A.L.U.C. COMPENSATION INSURANCE ('This section need not be completed if the peril is for one PLG. CONTR. LIC. NO. PLG. / TOTAL G6• Y ❑ N ❑ Y ❑ N❑ hundred dollars IS 100) or IcssJ 1 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 DTV. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 PLAN CHECK FEE emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT (TO 10=11F.M.) 4.00 AIR HANDLING UNIT (OVER 10=1C.F.M.) 6.00 SEISMIC FEE CO NSTRUC1ON LENDING AGENCY 1 hereby affirm that (here is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 the 3097 performance of the work for which this permit is issued (Sec. MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Name H EATI N G UN IT (OVER 100,000 B.T.U.) 9.50 ELECTRIC Lender's Address 1 certify that I have read this application and state that the above information is correct. I agree to conhply with all city and county ordinances untl state laws relating to building construction, and VENTILATION FAN (SINGLE) 4.00 PLUMBING 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-mentioned property for inspection purposes. MISC. - • REFER TO ORD. CONST. TAX (We) agree to save, indemnify and keep harmless the City of Cupertinagainst liabilities, judgments, costs and expenses which ino any way accrue against �id Ci(y in consequence of the PERMIT ISSUANCE 10.00 mnl go' his ennit. o?'o;LAg- MECH. CONT. LIC. NO. TOTAL TOTAL nature of Applicant/Can ractor Dale OFFICE COPY