6371 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IEDE;NTIFICATI ON PERMIT NUMBER
mut. G APPLICATION & PERMIT _ 6371
ADDRESS
BUILDING ry.ELECTRICAL PLUMBING MECHANICAL
r OWNLR'S �4" ! y vp,�^�x.1 I 'ppm •-�,,.� rlM1 � PLAN CHECK VALIDATION
"AME / TV' L�+!'k+ ' ELECTRIC,PERMIT
/ vHONE C/ N., mwvG' M1".y rT':- . Y.t�;. t ..J.•.�,
cO RACTCHS OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
LIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.0D PLAN CHECK FEE P.Q NO.
OR
ENGINEER
LIC.NO ISIGNS TRANS. 3.0
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
A D GRESs
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADORE SS
SERVICE CHANGE (^ 10.00
W o O LICENSED CONTRACTORS DECLARATION Lo CV/E JZ/! T
a u u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
n a i% I'm mmenculg with Section 7000)of Division 3 of the Business and /. BLDG. ELECT. PLG. MECH.
N i Professions Code,and my license is in full force and effect. e ❑ ❑ ❑ ❑
z o m - License Class_ Lie.Nwn be
O z H° Dale Contractor f �' / City of Cup rtino u¢ ."yBUIL'DI_NG�?ERMITd"1`
a w a OWNER-BUILDER DECLARATION ;-.F a'�INF,O{UYIATIONysys- I'"
a. A r 1 hereby allirm that I am exempt from Om Contractor's License MISC.- ER TO ORD -
u0A Law for the following mason.(See.7031.5,Businessand Protassions PERMIT ISSUANCE 6.00 (p C>_ VALUATIONS S/FT.
Code:Any city or county which requims a permitto construct.altar. �
IS to¢ 2O improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR. LIC.NO. ELEC.
- o M requires the applicant for such permit to fil...igned statement that TOTAL PpERpMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License ,'T�C_'_•I- - ' „n. xy-1. v °`=` p EQO
Hsi
Law(Chapter 9(courmenesngwith Section 7000)ofDWlsmn 3 ofthe `ts4i.i I^� Ab -.r.^••^• �" - d Ad fit +(P"{Y1't'41.. Qy ''�' /\ �CS
a Business and Professions Code)or that he is exempt therefrom and OTV-; 'T� g PLUMBING PERMITF,EE. '
¢tim the basis for the alleged exemption Any violation o Section 70315 Jwaq '-!y t`t" -'�I'ti "�s`'4-`c"r Zi< i't ?�.1�T'^ STORIES TYPE CONSTR.
a ; _ by any applicant fora permit subjects the applicant to4civil prnalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 O 144
of not more than five hundred dollars 155001.):
❑ h as owner of the property,or my employees with wages as BACK FLOW PROTECT-DEVICE 2.00 OCC.GROUP RES.UNITS
-Their sole compensation,will do the work,and the sttocture,is not
• intended or offered for Sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 C;Tit 4 ino
Code:The Contractor's License Law dues 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 or through his own employees.provided that such improve- GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
rents are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or ice- RES IND CON PB Omer
move for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
❑ h as owner 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 Contractors License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.2001t/8.00 TRACT N0. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sec. .B.&P.C.f.,this WATER HEATERW/VENT 4.00
minim"
a on
Owner Dare _ WATER SYSTEM 4.00 qCC.DATE qCC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm out I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereoflSce.3800,Lab.C.L
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z_ z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. Y ❑ IN Y ❑ N❑
Applicant
F- PERMIT ISSUANCE 6.00 FLOOD2oNE A.L.u.C.
CC - CERTIFICATE OF Ii XEMPfION FROM WORKERS'
LLI J COMPI'NSATION INSURANCE PILO.CONTR. LIC.NO. PLG. ❑ ❑ ❑ ❑
4. 0 (This eectior need not be completed if the permit is for one TOTAL v " v N
Z hundred dollars 1S 1007 nr less.) Im
I*mj ;a�q�'.`_ ix 1.AJ5.0 4't+�CR T L w,x r Ty,,,,tatU O 1 t ty that 'n the actformance of the work for which this p a ar_MEC HANICAL•PERMIT,e=+ `SFEE41 ,r d g PEESUMmit Iv iss I J I shall not nnpluy any person In any manner w a t9 L) M f ',?'GrvTa„".w i;1'L'?e 4 ATt .e:Jt_..: -f�.'�'1i r.,>.:csx ��UO D,tc sublcU to the Warkars COnTpcnsaDon Laws o(Calilornu' BUILDING
Date Applicant ER OR ADD TO MECH. 4.00crolni R TO .should beco IL after making this CaCompe of lix-
z crnpliion you should become subject m th4 Workers'CompensationLIANCE 4.00 PLAN CHECK
prisions nl' the Labor Cade, you must forthwith comply with HANDLING UNIT(TO I0=C.F.M.) 3.00FEE
such provisionsor this permitshall he Jeunedrevoked.CONSTRUCTION LENDING AGENCY HANDLING UNIT(OVER 10,o00C.EM.) 5.00 SEISMIC FEEI hereby affirm that there is a construction lending agency forHAUST HOOD(WITH DUCT) 2.00 MICROFILM
the performance of the work for which this permit is issued(See. ATING UNIT(TO 100,000 B.T.U.) 4.003097.Civ.C.).
Lender's Nance ATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC 4'y
Lrn certi y thatII ready that l hava mad rias tocomply and Mato ty a the aboveNTILATION FAN (61NGLE1 3.00 PLUMBING
ordina ccs n correct I agree ti comply with all city and countyLER-COMP(3 H.P,or 100,000 B.T.U.) 4.00ordinances and sWe laws relating to building c nster tion, thehereby enthoriec reperty moves ec this city es ancer uPml theILER-COMP IOvar t00,0000TUl SEE FEE SCH. MECHANICAL
abuvo-mentioned property for inspection purposes.
lWe) agree to save, indemnify and keep hrmless the City ofC.- REFER TO ORD. CONST.TAX
Cupertin against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00
may in m way accrue against said City in consequence o1 the ,(
graNin 1 is pcmliL / MECH,CONT, LIC.NO. MECH.
orALpfTOTAL'-"Z
-a sr _ -�r. w Ne Wit• tiA
Signmurc of Appl¢ant/Contractor Uate
OFFICE COPY