8526 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
�( BOILOiNG APPLICATION & PERMIT
RooflessQ �`�
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL (u�
` , OWNER'S PLAN CHECK VALIDATION
Axl N p
N GQ V 1&�4 >r7�s'� CITY. ELECTRIC PERMIT ,FEE-
<.x!l/��� PHONE OW
OONTRACTOR3
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. LIGHTING FIXTURES 10.00/1.00
CONTflACTOR'6
AooREss APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00
AflCwTECi DATE OF APPLICATION
Ofl PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.-N0.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH,OR ENG.
AooREss SPECIALCIRCUIT 5,00 PERMIT VALIDATION
AZIP EMP.METER OR POLE INS. 20.00
ADDRESS oREss MOTORS SEE FEE SCH.
¢ i SERVICE CHANGE 20.00 �.
o
Foo LICENSED CON TRACTORS DECLARATION TEMP.POLE 30.
< u I hereby affirm that 1 am licensed under provisions of Chapter 9
y a y (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
F,y z Professions Code,and my license is in full force and effect BLDG. ELECT. PLG. MECH.
z 0 w - License Class Lic.Number. C❑ ❑ ❑ ❑
om H w DateContractor JJ
¢ se s J :rBUILDINGIPERMIT:'::
s 0 w OWNER-BUILDER DECLARATION
X ;LL r- I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TOO 0 INFORMATION'
r u o J Luw for the following reason.(Sec.703 L5,Business and Professions PERMIT ISSUANCE VALUATION $/FT,r
� mj Code:Any city or county which reyuiresa penninoconslructalter, 10.00
U
¢OF improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. - LIG N0. ELEC.
AD Ix requires the applicant for such permit to filo a signed statemcnl that TOTAL
W ,A he is 11CCn5Ctl pprsuatlf to lI1B proVision5 Of the Cnnlrnclo!S Lice31W s� PERMIT TO
the
Fza Lew(Chapler9(commencingwith Section 7000)of Division Sof �,rC L(/ ON
i o Business and Professions Code)or that he is exempt therefrom and OTY. - PLUMBING PERMIT .FEE ts�
¢ I- $ the husis for the alleged exemption.Any vinlmion of Section 7031.5 C
n3 � by any applicant fora permit subjecn the applicant toncivilpenalty
of not more than five hundred dollars(5500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00 STORIES TYPE NSTR.
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT
❑mir sole compensal ion,-will tlo the work,and the strucRme is not .DEVICE 4.00 OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONO. 5.00
Code:The Contractor's License Law does not apply to an owner of
. properly who builds or improves thereon,and who dues such work FIXTURES-PER TRAP 5.00
himself or through his Own employees,Provided that such improve. SO.FT.FLOOR AREA TOTAL ACREAGE
ments are not intended oroffered forsale.If,however,the building GAS-EA.SYSTEM-1 INC.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 am- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
ave
for purpose of Sale.), BUILDING
RES I
censed ND CON PB Other
INDUSTRIALWASTE INTER. 30.00
I,as owner of the property,am exclusively contracting with RE ❑ ❑ ❑ ❑
licontractors to construct the Project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B.
ant]Professions Code:The Contractor's License Law floes not apply 6.00 ASSESSORS PARCEL NO.
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a mo ractons)licensed Pursuant to �/�/�
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/4&00 TRACTNO. PARCELNO,
real In t dSB.&P.C.for this
nm •mpuner ea , WATER HEATER W/VENT
Owner 6.00
11 Date WATER SYSTEM 5.0011
ACC.DATE ACC FILE NO.
WORK F,RS'COMI'CNSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby of firm that I hove a cert ificme of consent 10 self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.L
Policy No..Company SAN
0 ❑ CertillcJ copy is hereby ILrnished.
Z Z ❑ Certified copy is filed will, the city inspection division. r FIRESPRINK ENERGY T 24
FCC- O Applicant MISC.- REFE TO RD.N v N v NNE]CERTIFICA'I'Ii OF EXEMPTION I7ROM WORKERS' PERMIT ISSUANCE O FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG,CONTR. LIC.NO.
O. O PLG. / ❑ N❑ Y❑ N❑
� 0 This section need not be completed if the permit Is for one TOTAL Y
U O hundred, cert fy llarsthat in the
less.)
I certify that h the performance of the work for which this per. FEE SUMMARY
LL U mit is issued,e I shall not employ any person in any manner so is to QTY. MECHANICAL PERMIT FEE
O W become subject to the Workers'Compensation Laws of California.
BE. Datt,NOT Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} Z NOTICE TO APPLICANT If,after making this rs'Compe of ton
F - Provision you should become e, you in the Workers'Ccomply with APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with '
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=1C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 6.00 SEISMIC FEE
I hereby affrm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec.
en7,Ci Nome.).
LNa
Lender's HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
L
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.19.50 ELECTRIC
I certify tl,m I have read This applicatien and state that the above VENTILATION FAN (SINGLE) 4,00
.
information a correct I agree to comply with all oily and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authoriec represental sues nl' this city to enter upon the
above-mentioned property for inspection purposes. 801 LER-COMP(Over100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertl against liabilities,judgments, costs and expenses which
may f�ny way a rue ag���MMMJJJfff said City in consequence of the PERMIT ISSUANCE 10 QQ CONST.TAX
a ��ispee CJ MECH.CONT. LIC.NO. MECH.
4 �/� TOTAL
ignamrc of Apphcanl/Contractor Date TOTAL
OFFICE COPY