12018APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USAF. BALL POINT PEN ONLY
bUI LDI NG PROJECT I DENTI TION
APPLICATION MIT
MECHANICAL
PERMIT NUMBER
12018
BULLOING
ADORE D 7
OWNER'S
Nj E a3T •(1[j �(J
Ni j'�1.�� vHaNE-
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
'
DATE APPLICATION
CONTRACTORS
AME /.
fJ sec. Noy $a
OUTLETS -SWITCHES -RECEP 10.00/1.00 S
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
DOREs
e PITONXJ�
PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00 O .�
ARCHITECT
OR
ENGINEER
Luc. NO.
PANELS (OVER 200 AMP) 2000
PLAN CHECK FEE P.C. NO.
K
SIGNS TRANS. 3.00
ARCH, OR E
ADDRESS
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
`Jl y0I p 1'
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with S, 'find 7000) of Division 3 f 1ryt�5 and
Professions Ccd t n license is in full r1., ah�H a
Liccn ss ll....""^`VVV// Lic. Nudi i l
BLDG.
❑
ELECT.
PLG. MECH.
❑ ❑
Dere Contractor w r
BUILDING PERMIT
OWNER -BUILDER DECLARATION
I hereby affirm that I so exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requirespermit to construct, alter,
improve, demolish, or repair any structure, priorits issuance, also
requires the applicant for such permit 10 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 isexempt therefrom and
INFORMATION
M ISC.- REFER TO ORD
VALUATION
PERMIT ISSUANCE 10.00
ELEC. CONTE. LIC. N0.
ELEC. .Ln
TOTAL // � j
PERMIT TO
r- �_r
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
ALTER-DRAIN&VENT-WATER (EA.) 5.00
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollms (5500).):
❑ I, as owner of the property, or my employees with wages as
their sole compensation, Will do the work, and the Structure is not
BACKFLOW PROTECT. DEVICE 4.00
DCC. 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 does such work
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve-
mentsarenotintendedoroffered for sale. If, however, the building
GAS - EA. SYSTEM -11 NC. 4 OUTLETS 6,00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
13 1,
1, as owner of lire property, um exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Omer
El 1:1 1:1 ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
licensed contractors to construct the project (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
contracts forsuch projects with a contractorls) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
Cl lam exempt under Sec. ,B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
5.00
WATER SYSTEM
ACC. DATE
ACC. FILE NO.
WORKERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
t I ha cert c 'ent to self -insure,
or a certirker C m ion I NOCe, or a Certified
1 herebWNSATIOeN'11ONS
ZONING
ENG. SITE NO.
copy ther00
Policy Notrip I❑
FIRE SPRINK
ENERGY T-24
CerIle This
❑ Ceri RI Ic city inspection division.
V ❑ N ❑
Y ❑ NCE
MISC.- REFER TO ORD.Applicant
EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG. CONTE. LIC. NO.
PLG.
TOTAL
F.NSATION INSIT Ii
fThis section need not be completed if the permit is for one
V ❑ N❑
Y ❑ N[]
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars (S100) or less.)
I certify that in the performance of the work for which this per,
mil is issued, I shall not employ any person in any manner so as to
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex.
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=17-F.M.) 4.00
AIR HANDLING UNIT(OVER IOAOOC.RM.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
1 hereby affirm that there is a construction lending agency for
DIe Performance of the work for which this permit is issued (Sec.
3097, CIv.CJ.
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lender's Name
Lender's Address
VENTILATION FAN (SINGLE) 4.00
PLUMBING
It
I certify that 1 have read this application and state Ilial the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
BOILER -COMP 13 H.P. Dr 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 pmpc for ins n r us.
(WeVagteeto , i de and harmless the City of
MISC.- REFER TO ORD.
Cupertiil' a gme osis and expenses which
may inr ainst r' ity in consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
MECH.CONT. UC. NO. MECH.
grantin
TOTAL
TOTAL
Signature li n Ir r Date
a
/ V OFFICECOPY