13089 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BDw,„G APPLICATION & PERMIT
=a 99 � T 13089
UILDING -ELECTRICAL-PLUMBING-MECHANICAL
' O ERS PLAN CHECK VALIDATION
DTV. ELECTRIC PERMIT FEE
ONTRACTOR'E
OUTLETS-SWITCHES-RECEP 10.00/1.00
ucN LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADORE
PHONEPANELS 10.00 DATE OF APPLICATION
A RITE PLAN CHEC
oR ti PANELS (OVER 200 AMP) 20.00 K FEE P.C.NO.
ENGINEER//M/q„ (�-^
AGN/L! o. SIGNS TRANS. 3.00
noir'Ess OR UNG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 -
ADDDRESS
APPLICANTS MOTORS SEE FEE SCH.
' /
SERVICE CHANGE 0
w o o LICENSED CONTRACTORS DECLARATION
4 u w I hereby affirm that I am licensed under provisions of Chapter 9 I 0 10I t7 ISSUANCE DATE
y (commencing with Section 7000)of Division 3 of the Business and
a BLDG. ELECT. PLG. MECH.
F z L,eco.o.1 Co Id my lieense is in full for n ff ❑ ❑ ❑ ❑
it,2 o `r�' - License 1 Lin.Numhcr City of Cupert no
G N F o Dale Contract
a Y < BUILDING PERMIT
a OWNER-BUILDER DECLARATION
o> U INFORMATION
w g;LL I- 1 for the
affirm that I am exempt Im.5 the Contractor's License MISC.- REFER TO ORD
VALUATION E/FT.
LL o Law for the following my which
.(Sec.requires
a,H itocom Professions d
I- - PERMIT ISSUANCE 10.00
3 w 4 Code: e,them cityor county any stmeltum permit prior
to is issuance,
also
ec ¢ o requires,demolish,or repair any structure,prior tD its issuance,also ELEC.COrvTR. LIC.NQ TOTAL
O t<
requiresisic the applicant for such permit In rile a signed actor's Li that TOTAL �' PERMIT TO
w $ heir(Chapter
pursuanten the provisions of the )of flivni Contractor's License
F z a Law ress and professions
C d with Shahan 7s exempt therefrom
om the
and �� EL-�-7
4 o Rosiness and Profsg d eCode)or than he is tion of therefrom and CITU. PLUMBING PERMIT FEE
F $ the balls for the alleged aJ exemption.Any violation of Section malty STORIES TYPE CONSTR.
a � by any applicantforlive unnit subjects the applicant toacivil penalty ALTER-DRAIN VENT-WATER (EA.) 5.00
of not moa than five handed Aollars(5500),1:
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for wlc (Sec. 7044, Business and Profession' DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Conhactor's License Law does not apply to an owner of
• property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 as Fr.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsamnotintendedorofferedforsale.It,however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or ma. RES IND CON PB Omer
prove for purpose of sate). INDUSTRIAL WASTE INTER. 30.00 El ❑
❑ I,as owner of the property,am exclusively'contracting with El El El
licensed contractors to construct the project(Sec. 7044, Busio. LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cale:The Contractor's License Law does not apply
to an owner of property who tugs or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for.mch projects with a contractorts)licensed pursuant to SEWER-SANITARY-STORM EA.200f1/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec.-,B&P C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPF.N'SATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby effurn that I have a certificate of consent to self-insure. ZONING or a certificate of Workers'Con" 'tion Insuranc or u certified, ENG.SITE NO.
copy thereof(Sec.38OQ Lsb.0
Policy No. Compo
0 ❑ Certi led opy is heruy rnished. FIRE SPRINK ENERGY T-24
O A❑InAJnn' and p is fi d th cit inspersion division. MISC.- REFER TO ORD. v N Y N
�/a PERMIT ISSUANCE 10.00 ❑ ❑ ❑ ❑
- CF. ICATE F E IPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
LU COMPENS 'ION INSURANCE PLG.CONTR. LIC,NO. PLG.
CL 0 (Thu section need not be completed if the permit is for one TOTAL Y❑ NEI Y ❑ NF]
::) Z hundreddollars($100 .,le..)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, 1 shall not employ any person in any manner w as to
Ow become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
} 0 NOTICE TO APPLICAM': If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 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 1QMOC.F.M) 4.00
CONS'I'RUCfION LENDING AGENCY - AIR HANDLING UNIT(OVER 10=CF.M.) 6.00 SEISMIC FEE
I 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. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI NG UN IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC ' r 3U
1 certify that I have read this application and state that the above F
ON FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county P 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize aprexntativp of this city w enter upon the
BOILER-COM (Over t00,0008TU15EE FEE SCH. MECHANICAL
hove-mentioned property for inspection purposes. -
(We) a ce to sive, indemnify and keep harmless the City of REFER TO ORD.
Cupertin wast liabilities judgments, costs and expenses which CONST.TAX
may i i n way accmc s jud said City in and expenses
of the PERMIT ISSUANCE 10.00
gamtin of his Permit. ( 3 MECH.CONT. LIG NO. MECH.
TOTAL TOTAL
Signet of Applic t/Co etor ate
OFFICE COPY