7125 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
. . PERMIT NUMBER
BUILDING PROJECT I DENTI FICATI ON a c. '
auILOING
LA-11 ; APPLICATION & PERMIT 5-
�asa J
BUILDING ELECTRICAL-PLUMBING-MECHANICAL
0 NER'S - PLAN CHECK VALIDATION
1ti NAME - TV ELE� TRIC'PERMI
IS P FEE. PHONE
CONTRACTOR'S UTLETS;SWITCHES-RECEP 5.00/1.00
MF
-1 ^.im.N LIGHTINGFIXTURES 5.00/1.00 -
CONTRACTOR'S ', p"/1 APPLIANCES-RESIDENTIAL '4.00 �is
' ADaR s [7 !/ '
PH0IiE 351' PANELS 5.00 DATE OF APPLICATION
ARC ITECT _ - SIGNS 6,00 - •PLAN CHECK FEE P.C.NO.
OR
ErvmNEER
LIC.
-! SIGNS TRANS. 3.00 '
ARCH.OR ENG. - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION r
ADDRESS
•'ZIP EMP,METER OR POLE INS. 15.00 1 _
APPLICANTS' i - MOTORS ' . ,1 SEE FEE SCH.
'ADDR E Ss
' - SERVICE CHANGE '. 10.00
,woo LICENSED CONTRACTORS DECLARATION - __
a U I hereby at that I am licensed under provisions of Chaplet 9 ISSUANCE DATE
y a m (commencing with Section 7000)of Division 3 of the Business and BLDG- ELE PLG. MECH.'
H m z Professions Code,and my peens"e is in full force and effect. -
z o o - License Class' Lic.Number - '
0 w r woDate Contractor -
- BUY°DPyERMIT
¢ w ¢ OWNLR BUILDI R DECLARATION� - IAORMATION
wod- - MISCREFER TO ORD -`''-
; u I hereby affirm that 1 ain exempt from the Contractors License VALUATION S/FT.
FLLof Law forthe followmgreasom (Sec 7031.5,Business and Professions PERMIT ISSUANCE - 6.00 ..
io
Code:Any city or county which requires a permit to construct,alter,
rca a improve,demolish,of repair any structure,priouto its issuance,also ELEC.CONTR. LIC,NO. ELEC.
aa
G ¢ requires(he applicant for such permit to file a signed statement that TOT A / PERMIT TO
whe Is licensed pursuant to the provisions of the Contractor's License - - !
F z i Law(Chapter 9(commencingwlth Section 7000)ofDivision 3 oflhe #' "=' $'a Y s A tk.R C 'v V- W w
M�
¢ Business and Professions Code)or that he is exempt iherefroiv and QTr,Y,. PLUMBING PERMIT PEE
¢ F Oo the basis for the alleged exemption.Any violation of Section 7031.5 A � x¢w.`s- .+mar w L 1 „4vo-' STORI S TYPE CONS`M.
au -n by any applicant for a permit subjects the applicant Dia civil penalty ALTER-DRAIN&.VENT-WATER IEA:14.00
of not more than five hundred dollars($500).):
I,as Owner Of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 oce.GROUP RES.UNITS
their sole compensation,will do the work,andthe structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
3 property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through hisown employees:.provided(hat suchimprove-
ments are not intended oroffered forsale.If,however,the budding GAS-EA.SYSTEM-I1NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM'-OVER 4(EA.) 1.00 BUILDING USE
builder will have tire - .e burden of proving that he did not build or un- - - RES IND CON PB Omar
prove for purpose of sale.). x INDUSTRIAL WASTE INTER. 20.00 ,
❑ 1,as owner of the properly,am exclusively ecanDreting will, ❑ ❑ ❑ ❑ ❑'
licensed commences to construct lite project(Sec.7044,Business LAWN SPRINKLERS'1 INC 5 V.B. 5.00 ASSESSORS 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
contracts for such projects with a contractons)licensed pursuant to
lhCCmuDw(or's License Law. SEWERSANITARY-STORM EA.200ft/8.00 .TRACT NO. PARCELNO.
t] 1a exempt under Sean&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner - -pate WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I'have'a certificate of consent to self-insure, ZONING ENG.SITE NO:
or a certificate of Workers'Compensation Insurance,or a certified'
- copy thereof(Sec.3800,Lab.C.L
Policy No. Company `� -
" O- Certif• copyishcrcby msh d-•• .� 'e _ FIRESPRINK ENERGYT-I4
Certif a pY file x [h the'city spe bon division.
- -
p ppb-' t-Fyyd� �N .� MISC.- REFER TO ORD. v❑ N❑ v ❑- N❑
CC „/,(. PERMIT ISSUANCE 6.001FLOOD ZONE. A.L.U.C..
en
L � CE 'ICA P - MINION FROM WORKERS'
LIJ _ CO PEN TION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL o _ (This section need not be:completed if the permit is for one TOTAL Y❑ NE] Y❑ N❑
Z 'hundred Dollars($100)or less.) , ' 'g,'aq. + ?^. w'x " er
+U O 1 certly,that in(lie performance ol'-the work for which this per- QTY. MECHANICAU ERN11 FEE FEE UMMARY
LL H nut Is issued,ed,I strait not employ any person in any manner w a to e Dq). , ,G`
O become subject to the Workers Compensation Laws of raw rma. - + -
Ow Date APPlicant BUILDING -
a ALTER OR ADD MECH. 4.00
},tO NOTICE TO APPLICANT: If,after making this Certificate of F.x-
F•Z emplion,you should become subject to the Workeri Compensation 'APPLIANCE _ 4.00 PLAN CHECK '.
.provisions of the Labor Code, you most forthwith comply,with FEE
CJ such provisions or this permit Strait be deemed revoked. AIR HANDLING UNIT 10MOCF.M.) 3.00
• IT- AIRHANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby'affrmythat there Is a construction lending agency for EXHAUST 1-1000WITH DUCT) 2.00
lire.performance of the work for which this permit Is Issued(Sec. MICROFILM
3097Civ.C.). HEATING UNIT(TO.100,000.B.T.U.); 4.00 '
Lender's Name' HEATING UNIT(OVER 100,000 B.T.U.)7.50 '
Lender's Address ELECTRIC
I ectify,that)have read,this application and state tlmt'lhe above VENTILATION FAN (SINGLE) 3''.00
0 intororafon.is"Correct I agree to comply with all city and county - PLUMBING
mdmanees and state laws relating to building construction, and BOILER-COMP.(3H.P.or 100,000B.T.U.) 4.00
heaby,.authorize representatives of this city to enter upon the ,BOILER-COMP (Over 100,000STU)SEE FEESCH. - MECHANICAL
above mentioned property for Inspection purposes:
"(We) agree to save„indemnify,:und keep harmless file City.of MISC.- REFER TO ORD!
Cupertiri against liabilities,judgments, costs and expenses which' CONST.TAX
may i an way accrue,a st said City in consequ nee of the - PERMITJSSUANCE 3.00 ,
gra Dg of this parmlt. ;,. y, MECH.CONT LIC NOI MECH
TOTAL aTOTAL
Sign5life of Appli d/C r ac or
.. . .. • .'OFFICE.COPV- .. .. -
' .. ; "