3160 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ON ` 1
BU I LD ING PROJECT I DENTIFICATI ON DOILOING PE ITN. RER \
APPLICATION & PERMIT 3160
ADDRESS
� o q,00 Q "• v BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNCER'S PLAN CHECK VALIDATIDN
NAME /� QTY. ELECTRIC PERMIT FEE
CONTS YV/'I PHONE �/YG I/pp��
NANTRACTORs AME OUTLETS-SWITCHES-RECEP 5.00/1.00
Sera,-Cr OG"�t4t� No.� �//3/ LIGHTING FIXTURES 5.00/1.00
ADDess ORS APPLIANCES 4.00
75/ PHONE 3LY dla7 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P,C.NO,
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH OR ENG. - SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDESE
ZIP FEMP.METER OR POLE INS. 15.00 n //
APPLICANT S MOTORS SEE FEE SCH. !�/(/}/[�•/a/'�1
ADDRESS
SERVICE CHANGE 10.00 �J �-• pJ'
02 LICENSED CONT'RAC'TORS DECLARATION �C �✓ �O J
Q v u I hereby affirm that I an,licensed under provisions of Chapter 9 ISSUANCE DATE
N Q N (efurnoCncing with Section 7000)Of Division 3 of file Business olid BLDG. ELECT. PLG. MECH.
H D z Profession,Cody iD�y yy//license is in full fore�^y ji ❑ ❑
ZOm License Clyss_C-SY Lic.Number 7� ❑
q z H Date1..`/.S(/ES-Conlractorv_ttf.t�'eG/�-
ij, BUILDING PERMIT
w a OWNER-BUILDER DECLARATION
o A MISC.- REFER TO ORD INFORMATION
3 U 1 hereby artium that I um exempt front the Contractor's License VALUATION $/FT.
F u_o j Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requiresa permit toconstruct.a teq
rt ¢ Q Improve,demolish,or repair any stn clan.prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ou
O IC requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w Ci lie is licensed pursuant to fire provisions of the Contractor's License
H Z Q Law(Chapter 9(commencing with Section 7000)of Divisiml3 Or til. /4 C/�
4 C Business and Professions Code)or tour he is exempt therefrom and QTY. PLUMBING PERMIT FEE
It I- lire basis for the alleged exemption.Any violation of Section 7031.$ 1 STORIES TYPE CONSTR.
w. ;� by any applicant for a pennif subjects the applicant to a civil penalty ALTER-DRAIN -WATER.IEA.) 4.00
of not more than five hundred doll...(5500).):
❑ I,us owner of me pwpeny,or my employees wit.wages a. BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the Moncton,is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:'file Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 sD.PT FLDOR AREA TOTAL ACREAGE
himself or through his own evnployecs,provided that such improve- OD
ments are not intended or ol'tered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
huibler will have the burden of proving that he did not build or im-
provefor pmposeofsale). INDUSTRIAL WASTE INTER. 20.00 RES IND CON Pro Omer
❑ I,as owner of the property,am Cxclmively cuntrucling with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the 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 un owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with.contractoe,)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-ST OOft/8.00 TRACT NO. PARCEL NO,
❑ I in.exempt under Sec ,B.&P.C.for this WATER HEATER W V E NT
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK E RS'COM PINSATION DECLARATION WATER TREATING E♦QUIP. 4.00
I hereby affirm (1141 1 have a certificate of consent to self-insure. CSL ZONING ENG.SITE N0.
or a certificate of Workers'Compensation 1 su once,or.ce Iificd
co thereof(See 3800,Lab C.).
policyNm
n. Copany ��
Q ❑ Certified copy is hereby furnished. R/ FIRE SPRINK ENERGY T 24
z ❑ Cer6 pY.w fi}x'�I w' lire city inspection division. MISC.- REFER TO ORD. Y E] NY [D NE]Applicant- - /_�r ❑
� - CER1'IFICA1F OF EXEMPTION FROM WORKERS. PERMIT ISSUANCE 6.00 GD FLOOD ZONE A.L.U.C.
LJ > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. Oo Y[:3 N❑ Y ❑ N❑
d 0 (This section need not be completed if the permit is for one TOTAL
Z hundred dollars IS 100)or less.)
U O I certify that in the performalice of life work for which(his per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
L_ P mit is issued.I shall not employ any person in any manner so as to
U become subject to the Workers'Compmo.lion Laws of California.
n Date Appllcaot ALTER OR ADD TO MECH. 4.00 BUILDING
} to NOTICE TO AI'PLICAN'I': If,after making this Certificate of Iix-
FZ emption,y ou should become subject In the Worken'Compensmion 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 10MCF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency lir EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097.Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.M50 ELECTRIC
Lender's Address
1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
40
infonnmmir is correct I agree 10 comply with alll city and county BOILER H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and slate laws relating to building or,tructmo, and
hereby authorize representatives of this city to enter Upon the BOILER-COMP)Over 100,000 BTU)SEE FEE SCH. MECHANICAL
.hove-mentioned properly for inspection purposes.
(We) agree to save, indemnify mud keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
graptrtlLAf Ihia prJllliL / �� MECH.CONT, LIC.NO. MEC
X V ti Z SSB OTAH.L
TOTAL
Signature of Applicant/Contractor Date
OFFICE COPY