6779 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - LISE.BALL POINT PEN ONLY
BU I LD ING PROJECT IDENTIFICATION ` PERMIT NUMBER
6UlcplrvGAPPLICATION & PERMIT
; Ito; ��jjyy--tt
Z LLQ /}fit BUILDING—ELECTRICAL—PLUMBING—MECHANICAL6779 .
OWNER'S - i1 .• % A} %- ",` % S % PLAN CHECK VALIDATION
NAME Q _,�77 QQ'' IS,a i a >N & 'a tS 4 #T Tr. .
Ally A� ? ® � PHONE��/'t/P� �� ' kr'ELECTRICrP,ERMITa v`9 q x �F,aEE
CONTRACTORS OUTLETS-SWITCHES_RECEP 5.00/1.00
NAME J,Uc.NO" LIGHTING FIXTURES 5.00/4.00
ADDR's
ADDRESS
- APPLIANCES-RESIDENTIAL'. 4.00 '
REss ^ y
PHONE 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. - PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT `5.00
nP , - EMP:METER OR POLE INS. ' 'E SCH.
ADDRESS rs +. MOTORS' ' - SEE FEE SCH. V
ADDRESS '
SERVICE CHANGE 10 O. 11z�
w o 2 LICENSED CONTRACTORS DECLARATION - - `( a
< o v I henchy affirm that I am liceRsed Roder provisions of Chapter 9 ,• ISSUANCE DATE
'a at w (commencing with Section 7000)of Division 3 of the Business and
Q H BLDG- ELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and effect. l V` ( 4
ow - License Class_ Lia Number
LwC
- o Daic' ' Contractor
F j
`BUILDING PERMIT
w OWNER-BUILDER DECLARATION
w ; a w I hereby alflrm that I am exempt from the Contractor's License MISC.— - REFER TO ORD ` z.^ 1NFORBr1AT10N,
�'- PERMIT ISSUANCE- 6.00 VALUATION $/FT.
a g Business and Professions
LL o j La for the city
or county reason.(Se 70resa
m � C prove,y dryer repair which strrequcture,
permit reconstruct,alter,also R aE/x V-
"Qp ¢ 0
improve, or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.'ND. - ELEC. '�'
a wD., requires Lire applicant for such permit to file a signed statement that TOTAL' PERMITTO
rc he is licensed pursuant to the provisions of the Contractor's License _ �= A-
Fz > Low fChapmr9(colvmenungwith Section 7000)of Dwlelon3 oRhe a> 'r, a r ".«"fY• - S7i"- ] �lV+ ,�'�
a Business and Professions Code)or that he is exempt therefrom and OTV fsa tf a %'e PLIJMBING'PERMIT zr t 1= STPEE Cl
M 1-m the basis for the alleged exemption.Any violation ofSection 7031 5 +t ¢ + . - s " x „* 1 + STORIES - TVP CONSTR.
d ; - by any applicant for a penult subjects the applicant to a civil penally ALTER-DRAIN (EA.)'4.00
ofnot more than five hundred dollars(S500).1: it UIlaWr 'SX/4 a-
❑ I,as owner of the property,or my employees with wages as. BACK FLOW PROTECT.DEVICE 2,00 OCC.GROUP .REB.UNITS
their sole compensation,will do the work,and the struclurciis not -
'intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 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 or through his own employees,provided that such improve-
ments
mprove- - -
mentiarenotintelided or ffered forsale.If,however,the building .GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS'-EA.SYSTEM-OVER 4 IEA.)
builder will have the burden of proving that he did not build or im- 1.00 BUILDING USE
prove for purpose of sale.). I INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omar
❑ 1,as owner of the property,am exclusively contracting 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 an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EAJ 1,00 - -
contract's forsuch p jecL with o contructorts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. 'PARCEL NO.
theCont fo,S e6seLaw- - '
❑ I am ^ e Ider See. B.&P.C.for thisson WATER HEATER W/VENT 4.00 '
Owne -Da!e WATER SYSTEM 4,00 ,ACC.DATE ACC.FILE NO,
WORKERS'COMPENSA'1'DON DECLARATION WATER TREATING EQUIP. 4.00 r
hereby affirm-that I have a certificate of consent to self-insure., _
or o cetlificme•of Workers'Compensation Insurance,or.a certified -ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company - -
O" ❑ Certified copy is hereby furnished. RE SPRINK ENERGYT2a
Z_Z ❑ Certified`copy,is filed with the city inspection division.
P: C Applicant - MISC.- REFER TO ORD, Y❑ NE] v ❑ N�
LUvCIRTI F ICA`TEOEIAOTIFROM ERS' PERMIT ISSUANCE 6.00
FLOOD ZONE A.L.U.C.
W > - COMPENTIN INSURANCE.-
PLG.CONTR. ;LIC.No: PLG.
CL O This section need not be completed if the permit Is for on - - TOTAL Y❑ N�' Y ❑ N�
D Z h ndr d dollars IS 100)or less.)
U O I c rtrfy [hat in the performance of the work for whmh this per OTtY:1`h` '+'`` �l, MECHANICAL`PERMITy- H",' ' 11FEEs'
LL 1- not is issued I shall not enl ploy any person in any mannerso as to v 4 , s
U become xobject m the Workers'Compensation Laws of California.
n Data Applicant - ALTER OR ADD TO MECH. ` '4.00 BUILDING A 3d''lSZ
} m NOTICE"f0 APPLICANTC: If,after making this Certificate of Ex-
^F Z' 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
(.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MDQF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1 .F,M.) 5.00 SEISMIC FEE' Idv .
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) . _ 2.00
the performance of the work I'or which this permit is issued(Sec. MICROFILM
3097,CR.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name HEATING UNIT I0 VER 100,000 B.T.U.)7.50
Lender's Address - 'ELECTRIC.
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) ^_3.00
information is,correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building-construction, and 130ILER-COMP(3H.P.DI',100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Ova1100,000BTU)SEE FEE SCH. MECHANICAL
above-menlionedproperty far inspection purposes.
(We
)'agr to save,'mdemnil'y Vkeep harmless the City of MISC.- - REFER TO ORD, -
Cupertinys inst liabilities,judg frF, costs and expenses which `PERMIT ISSUANCE ' ' "3,00 - CONST.TAX
may ' way accrue again^ 9 City i 'consequ nce of the
gr in `lisp rm'. r// �" MECH.CONT. LIC.NO. TOTAL aae�x ¢ naTry.„'x
ti
fOTgAL= ,
Signature of Applicant/Conlmolor '-Data wT.-%Tr "Lk' - ✓
OFFICECOPY - -