13426APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT "
BUILDING —ELECTRICAL— PLUMBING —MECHANICAL
PERMIT NUMBER
91rIL01Nc
ADG A13426
OWNER'S
PLAN CHECK VALIDATION
AM ALT / It
PHONE'
` J HONE
DTV. ELECTRIC PERMIT FEE
n p D
T I�
OCT 19 1993
1
CONTRACTORS
N E n /� n /y `� �J/gyp �{
Sl ITlk CO�6, LIC No L / % UJ
OUTLETS - SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR' /'1 0/ �� OAPPLIANCES
WAL � 14 -a -L eA ,.ONE 44 I o
- RESIDENTIAL 4,00
- PANELS 10.00 ;q
oncHREc*
ENGINEER-
LIC. ND.
PANELS (OVER 200 AMP) 20.00
PLAN CHECKP.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENG
SPECIAUCIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
ZIP
111
A -
ADDDRESSDRESS
MOTORS SEE FEE SCH.
SERVICE CtjANI
-
LICENSED CONTRACTORS DECLARATION
1.. v� a —,
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) uC Division 3'of the BUCtless:md
Professions Cot Z � 'cense is in full for yp,t�fyey
License C Ss Lic. Number [? V� /
Date Contractor A66�d�r�
��'' ( , �4i
ISSUANCE DATE
--
BLD .
ELECT.
PLG. MCH.
IEJAp�
llnY
/'J�
DATE
BUILDING PERMIT
INFORMATION
' OWNER -BUILDER DECLARATION �, ii �'�eCC�_
-f hereby collo that 1 so exempt from the Contractor's License
Professions
Law forthecitylowingreason.ch c. lectures a Business to construct,
Code: wunty permitaoconsuance,
any
—
MISC. — REFER TO ORD
•- PERMIT ISSUANCE 10.00
VALUATION
` -
$/FT.
-
ELEC. CONTE. r LIC. N0.
ELEC.
TOTAL
e,demysh pair structure, priodSOter,
requirve, demolish, or repair any structure, prior t0 its issuance, also
requires the applicant for such permit to file a signed athat
he is licensed pursuant to the provisions of the Contractor's
dor's License
PERMIT TO
DTV. PLUMBING PERMIT FEE
I
the
Lasiness it Professions Codewith Section is 00) exempt
bass and Professions Code) or that he is exempt Therefrom and
the
the basis portae alleged exemption. Any violation oto ac Evil malty
by any applicant fora permit subjects the applicant toa<ivilpenalty
of not more than five hundred dollars ($500r) '.
STORIES
TYPE CONSTR.
ALTER-DRAIN&VENT-WATER(EA.) 5.00
❑ I, as owner of the property, or my employees with wages ns
their Sole compensation, will do the work, and the structure is not
BACK FLOW 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
property who builds or improves thereon, and who dues such work
himself or through his own employees, provided that such improve-
mems are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 5.00
GAS - EA. SYSTEM - I INC. 4 OUTLETS 6.00
SO. FT,FLOOR AREA
,
TOTALACflEAGE
or improvement is Sold within one year ofcompletion, the owner
builder will have the burden of proving that'he did not build or in,-.
prove for purpose of sale.). - • '' '
❑ I, as owner,of the property, em exclusively contracting with
GAS +EASYSTEM -OVER 4 (EA.) 2.00
- - 4
BUILDING USE -
RES IND CON PB Other
❑- ❑ ❑ ' ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
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
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 contractod a) licensed pursuant to
the Contractors License Law.
SEWER-SANITAR V•STORM EA. 2001t/10.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sea ',B.&P.C. for this
reason
WATER.HEATER W/VENT '. 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00 -
WORKERS'COMPENSATION DECLARATION
1 hereby affirm that 1 have a certificate of consent to self -insure,
or a certificate of Wo kers' Compensation Insurance, or a certified
copy there 0, Lab C.). '��,0/JN/ yJT
PGIicYN filed ISSPC
❑ Ce d herebyfurnished. /� /
etlified copy is fled with the ci 1 e 1101 division.
Applicant
20NING
ENG. SITE N0. -
-
-
FIRE SPR INK
v ❑ N❑
ENERGY �T24
v ❑ N❑
MISC. - REFER TO ORD.
CERTIFICATE OP, EXEMPT' ION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE,
A.L.U.C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
PLG. CONTE. LIC. NO.
PLG.
TOTAL
Y ❑ N ❑
Y ❑ No
hundred dollars IS 100) or less:)
I certify that in thee -performance of the work for Much this per-
mil is issued, I shall not employ any person in any manner so as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date ApplicantALTER
OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate oDEx-
-
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
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
' CONSTRUCTION LENDING AGENCY
I hereby affirm that there is's construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00 '
the performance of the work for which this permit isissued (Sec.
3097; Civ.C.).
•
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.
pe
Lender's Name
a
LenJer's Address
HEATI NG UN IT(OV ER' 100,000 B.T..U.) 9.50
�ELECTR IC
VENTILATION FAN (SINGLE) 4.00
I certify that 1 have read this application and state that the above
information is'correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING ..
-
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00 -
BOILER -COMP (Over 100,000 BTU) SEE FEE SCR.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO-
(We) agree to save, Indemnify and keep harmless the City of
Cuper'no against liabilities, judgments, costs and expenses which
ma any way accrue against said City in consequence of the
gr f this permit
O 3
Si a reo pmant/Con tractor - Date
CONST. TAX
"
- PERMIT ISSUANCE p
MECH. CONT. LIC. NO. MECH.
r�p TOTAL
S(�p "a7go3 Z
TOTAL
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