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
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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