3814 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
.BU I LDING PROJECT I DENT(FICATION R ITNUMBER
"
APPLICATION & PERMIT
au,Ln,NG 1 /I
AD o ec;t i, nda LA's f I `F
BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S - i - - - A HECK VALIDATION
" ME �l DL(.I IQC
O(iL I S V✓ OTV. ELECTRIC PERMIT FEE
PHONE
coMERacrORs unCIOUTLETS-SWITCHES=RECEP 5.00/1.00
h "
( le. ✓I I - .No. 'ref. L- LIGHTING FIXTURES 5.00/1.00
CONTRACTORS .6�^ APPLIANCES-RESIDENTIAL 4.00
PHONE' PANELS 5.00 PTE OF APPLICATION
DR 9�Q y 3 SIGNS E.00 LAN CHECK FEE P.C.NO.
rL•�/r /Z
N R f
LIC.NO. SIGNS TRANS. 3.00
ADDRRESS ENG. SPECIAL CI RCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 PAID -
APPLICANT'S
ADDRESS AMOTORS SEE FEE SCH.
SERVICECHANGE 10.00 JUL 5 - 1983
00 LICENSED CONTRACTORS DECLARATION .F
a u Su 1 hereby affirm that I am licensed under provisions of Chapter 9 tg Q,`ISO
s- "' (commencing with Section 7000)of Division 3 of the Business and mac BL EL PLG. MECH.
r w Professions Co my license is in full force n e
2.0 u - Licens Cla Lie.Number
2e 4
Dote - - Contractor
y s �'�I'FC d BUILDING PERMIT
tt ¢ OWNER-BUIL 'R DECLA A' IO
IS d u INFORMATION
W ; H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
Fu
L.
Law for the following reason.(Sec.7031.5,Business and Prnfessions PERMIT ISSUANCE 6.00 VALUATION $/FT.
0 � Code:Any city orcounly which requires a permit to construct,alter, - 700 , '
a O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
to ar O u requires the applicant for such permit to file a signed statement that TOTAL
E
uaRMIT TO
$ he is licensed pursnt to the provisions of the Contractor's License '77
r � Law(Chapter 9(commenoing With Section 7000)of Di vision 3 ofthe
Pi a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
IS the basisfor the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT, DEVICE 2.00 DEC.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,GOND. 4.00
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 4.00 SO.FT;FLOOR AREA TOTAL ACREAGE
himself re through his Own employees.Provided that such improve.building
hieets mself a not intended oroffered emplofee ,provided
that such
emg GAS-EA.SVSTEM-11NC.40UTLETS 4.00
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• GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
RES IND
pane of sale.)' INDUSTRIAL WASTE CON PB Osher
1,as o INTER. 20.00 0 D 11
❑ I,as ownernee of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I 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 contractor(s)licensed pursuant to
the Contractor's License i.e.. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec..,BAP.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 p❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-14
Z Z / Cerrif d co s flied'w' the cilyrl t speed division.
O Applicant ' MISC.- REFER TO ORD. Y� IN Y M No
(CL4 CERTIFICATE01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
LU J COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
n' O (This section need not be completed if the permit is for one TOTAL Y❑ N Y [ 'A
D 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 U mit is issued.Ishall not employ any person in any manner so as to
become subject to the Workers Compensation Laws of California.Date-Applicant BUILDING
ED ALTER OR ADD TO MECH. 4.00
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 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 10MC.F.M.) 3.00
CONSTRUCT'ION'LENDING AGENCY AIRHANDLING UNIT(OVER 10,000C.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.17.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
ordinance, is correct. I s rel ti comply withall city and county PLUMBING - .
ordinance, and irate laws relating to building construction, and BOILER-COMP(3 H.P.Of 100,000 B.T.U.) 4.00
hereby authorixa representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP to.,t00,000BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC. REFER TO ORD.
Cupertin against liabilities,judgments, costs-and expenses whichPERMIT ISSUANCE - 3.00 CONST.TAX
ay is ny way accrue against said City in consequence of the
ray
of this per 1t. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
f " j
Ig eture of Applicant/ Ont r Date
OFFICE COPY