12012 APPZICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
161ec APPLICATION & PERMIT 1201 Z
INDORESs
22 �V i BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
TME / 07. ELECTRIC PERMIT FEE ,
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CONTRACTORS G-/ a z UTLETS-SWITCHES-RECEP 10.00/1.00 pp
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oR!�ss R' �x�1� N.3e -t p PPLIANCES-RESIDENTIAL 4.00
I'1 . 14V yt y CIi CTPHONE[] I D\ 10.0DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CECK FEE
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OR
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ARCH.08arc. SPECIALCIRCUIT S.00 �V� PgR��}�yT�y IDATION
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SERVICE CHANGE 20.00 C
w 0 O LICENSED CONTRACTORS DECLARATION City Of CuDertfno
< u u I hereby affirm that I an licensed under provisions of Chapter 9 ISSUANCE DATE
h< w (commencing with Section 7000)of Division 3 of the Business and BLDG. E E PLG. MECH.
D'A Professions Code d1nyy license is in full far ygnd f t. ❑ ❑ ❑
2 0 0. �Licensef Cdns Coded
/ONumber O Jys -
w -tw Date
B Contractor
a y s BUI DING PERMIT
¢ ¢ w a OWNER-BUILDER DGCL RATION I FORMATION
MISC.- REFER TO ORD
K
u N I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
FLL04 Law forthe following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE ' 10.00 10'(.3z
Code:Any city or county which requires a permit to construct,alter,
Q Q Q Q Imps Ve,der110h5h,or RFIaI!any$[NCIUIe.prat to its issuance,llI50 ELEC.CONTR. LIC.NO. ELLE
n O LL requires the applicant for such permit to file a signed statement that TOTAL ERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License �,,Oy/ �'
Fi >
Law(Chapter 9(commencing with Section 7000)of Division 3 of the VV /
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
z=$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a. by Say applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(3500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCD.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec, 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
At
Code:The Contractors License Law does not apply to an owner ofproperty who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00SO.FT.FLDOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.I f,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or Improvementissold within one year of Completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDI uSE
Builder will have the burden of proving that he did not build or im- RES IND C PB Other
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSOr PARCEL NO.
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-OVER 5(EA.) 1.00
the Cons for suchprojects Lwith a contractorts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
thetract for
License Law.
O lam exempt under Sec.-,BAP.C.for this WATER HEATER WIVENT 6.00
reason-
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.
Policy No. Company •-`•xww`
O 0 Certified copy is hereb mishe .FIRESPRINK ENERGY T-24
Z Y-C'ertific copy is til with! � ins ec ' division.
O Ap llcant MISC.- REFER TO ORD. y❑ N❑ Y ❑ N❑
H
LAO
C.
&3PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
CC - CERTIFICATE OF EXEMPTION FROM WORKERS'
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y 1:1N❑
CL O (This section need not be completed if the permit is for one TOTAL
7) Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per, QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL 5mit is issued,I shall not employ any person in any mannerso as to
U become subject to the Workers Compensation Laws of California.
O y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT': If,after making this Certificate of Ex-
Z 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 10=C.F.M.) 4.00
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 3097 performance ante of the work for which this permit is issued(Sec. HEATING'UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
�I I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
(^ hereby authorim representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.'
(We) a Savs indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertin agar t liapilities,judgments, costs and expenses which CONST.TAX
may i any ay a -rue against said City in cons quence of the PERMIT ISSUANCE 10.00
granC is en it MECH.CONT. LIC.NO. MECH.
p 2 8- TOTAL TOTAL
Splamre of pp icant/Contractor Dal
OFFICE COPY