09842'xI APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION . PERMIT NUMBER
DDILoIyc APPLICATION & PERMIT
ADDRESS• BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 09842
D ,.S S /CULNS
OWNERS /, .,+ -
NAME + SGp)/ 0 r PLAN CHECK VALIDATION
yueft, G° , OTV. ELECTRIC PERMIT FEE
^PHONE3Z T. Z- Z
rcinme"trona OUTLETSSWITCHES-RECEP 10.00/1.00
U �$ w:7LIC.No. LO' LIGHTING FIXTURES 10.00/1.00
ADDRESS roll/s� Sr _x ,9y-OSO [� PPLIANCES-RESIDENTIAL 4.00
12-10 CQ e7srAA) SONE 8 $ PANELS 10.00 DATE OF APPLICATION
ORRCHITECT _ - PANELS 200 AMP) 20,00 PLAN CHECK FEE P.C.NO..
ENGINEER
LIC.ND. SIGNS TRANS. - 3.00
ADDRESS ENG SPECIALCIRCUIT. 5.00 ` PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.0 =0 <
ADDEMOTORS SEE FEE SCH. =BI�V`•"�
APDL RICASS
SERVICE CHANGE 20.00 ,T
'02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30,00 / /['s/
<i w I,hereby affirm than I am licensed under provisions of Chapter 9 ISSU NCE GATE
y Q•N (commencing will)Section 7000)of Division 3 of the Business and BLDG. . ELECT. PLG. MECH.
H N Professions Code,send my license is in full for effsct0OCT ❑ ❑ ❑
a Z g o License Class Lic.Number U D
o p 17,
firm Contractor a
a m f (,If - - BUILDING PERMIT.
a a M 4 - OWNER-BUILDER DECL ATIO INFORMATION
E
3: LL m 1 hereby affirm that I am exempt from lire Contractor's License MISC.- - EFER TO ORD
F u'ov, Law for the following reason.(Sec.7031.5,Businessand Professions . pERMIT ISSUANCE 10_.00 VALUATION S/FT.
g w 0 Cade:Any city or county which requiresa permit to construet,aIle" - + Q
o: ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR.' LIC.N0. - ELEC. .q 0 OrV
i w a M requires the applicant for such permit to file a signed statement that TOTAL V LT
he is licensed pursuant to the provisions of tire PERMI
e Contractor's License /s /T_T,VI O��G
H z a Law(Charter 9(eonunencing with Section 7000)of Division 3 of the `.
E 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
Ir: I-g the basis for the alleged'exemption.Any violation of Section 7031.5 - STORIES TYPE CONSTR.
n ; � by any applicantfpermit subjects lheapplicam io a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not mom than
n fiveve va hundreA dollars(55001.):-
Cl- ],.as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE, 4.00
their sole compensation,will do the work,and tire
e structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
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 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such'imprasvc- -
memarenotintendedoroffereAforsalell',however, building GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
or bnprovement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4 (EA) 200
builder will have the burden of proving that h - . - . .
e did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CONPS On.,
❑ 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. 6.00 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-OV ER 5(EA.) 1.00
+ . contracts for such projects wish a contractrn(s)licensed pursuant a . .
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. .'PARCEL NO.
` ❑ tum exempt under Sec ,BAP.C.for this WATER HEATER W/VENT 6.00 '
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARA'I'ION WATER TREATING EQUIP. 5.00 ,
I hereby affirm that 1 have a certificate ofconsent to self-insure. ZONING ENG.SITE NO.
�0 or a certificate of Workers'Compensation in ranee,or a cenil'ied
copy thereof(Sec.3800,Lab.C.1!.77 .G
Policy No. Com Pan y Z.LCf�
O ❑ Certified copy is hereby furnished. FIRE$PRINK ENERGY T24
Z ❑ CertiOe opy Is fit wit a city inspection division. MISC.- REFER TO ORD.
F�p(2� Applicant v N� y NF
cc: �- C. 11 FIC "i - e%Eh1Pl' N PROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C..
LU 7 MPENSATION INSURANCE PLG.CONTR. - LIC.NO. PLG.
CL Z (This section need not he completed if the no nn it is for one TOTAL Y C] N� Y C] NE]
hundred dollars 1$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 1- mit is issued,1 shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California.
0. Date ApplicantBUILDING
}m NOTICE TO APPLICANT: 11,after making this Certificate n1'Ex- ALTER OR ADD TO MECH. 5.00
F.Z "anption,you should become subject to the Workers'Compensation APPLIANCE - 5.00 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 10PWC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY' ' AIR HANDLING UNIT(OVER 10000 C.F.M.) 6.00 SEISMIC FEE - s
I hereby affirm 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(Sea - . MICROFILM
3097,Cw CA, � HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
®+ information is correct. 1 agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
oRlinmlcus and state laws relating to building Construction, and '
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
CupertiirliMir/C
=ttor
costs and sex PeG.S which PERMIT ISSUANCE . 10.00 'CONST.TAX
may inity in consequence of the
granti MECH.CONT. LIC.NO. MECH.
ser._ - TOTAL TOTAL
ignaluhale
OFFICE COPY