11849 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN,ONLY
: � BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 11849
ADDREs ING—ELECTRICAL—PLUMBING—MECHANICAL
OWrvER'S PLAN CHECK VALIDATION
..
NAMECITYCITY. ELECTRIC PERMIT FEE
EJGMC-O &/,z-7- 'PHONE
CON Across UTLETS-SWITCHES-RECEP 10.00/1.00NAMz
.No. o LIGHTING FIXTURES 10.00/1.00
CONTRACT R'S n/11/ ({'� PPLIANCES-RESIDENTIAL 4.00
R /r'1
PHONE PANELS 10,00 DATE OF APPLICATION
ARCH Lr PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ervc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.SERVICE CHANGE 20,00
0
'02 LICENSED CONTRACTORS DECLARATION 706,
< i w I hereby affirm that I am licensed under Provisions of Chapter 9 /s I ISSUANCE DATE
vHi¢ 'w (commencing with Section 7000)of Division 3 of the Business and �A•- BLDG. ELECT. PLG. MECH.
H y z Professions Code d. 'ease is in full fore
z 0 a+o License Clas Lie.Number J J 0 ❑ E
o L Date Contractor
a y -�+• Ct�S U BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION -
¢ INFORMATION
La ;n N I hereby affirm that I am exempt from the Contractor's License MISC.— REFE sTC11,b
H a. Law Law for the following reason. 7031.5,B usiness and Professions PERMIT ISSUANCE `' 1000 VALUATION $/FT.
Code:Any city or county which requires a permit to construct.alter, COY
E EC. NTR. LIC. 37�
¢ ee¢0 improve,demolish,or repair any structure,prior to its issuance,also ELED. //
¢ requires the applicant for such permit to file a signed statement that TOTAL 1 PERMIT TO
u w m.u. he is licensed pursuant to the provisions of the Contractor's License t
H z a Law(Chapter9(commencing with Section 7000)of Division 3 of the EGe'L7
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
at=$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A � by any applicant for a permitsubjects the applicant too civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the 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 Low 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 Improve-
mentsurenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA ) 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 CON PS Omer
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(See. 7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCELNO.
and Professions Code:The Contractor's License I.aw 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 with a contmetoAs)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for Olis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate if'cun,ent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Comp satlon nsurm a�, r a certified
Copy I' 800,Lab.C.l. I� r�/t
Policy Company
O ❑ Certified cop areb furnished FIRE SPRINK ENERGY T-24
Z Certified cor i i eh ect ion division.
Z , y MISC,- REFER TO ORD.
O A pl¢am _ Y [] NE] Y E] N[]
i N Clilt9'IFICATE OF EXE TION I°ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L C7IMPENSATI N INSURANCE PLG.CONTR. EJC.NO. PLG.
IL O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y F] Nf_]
D Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
Obecome subject to the Workers'Compensation Laws of California.
WDate Applicant BUILDING
0.>_ Go N01'ICE'I'O APPLICANT'. If,alter making this Ccrtificete of E. ALTER OR ADD TO MECH. 5,00
? emption,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 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1C.F.M.) 6.00 SEISMIC FEE
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(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 ,
Lender's Name
Lender's Address HEATING UNIT 100,000 B.T.U.)9.50 ELECTRIC I C - 3 Q
1 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 PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.)- 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEE BCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertin against liabilities,judgments, costs and expenses which CONST.TAX
may i a y way cme against said City in conacc ace f the PERMIT ISSUANCE 10,00
grant go this a MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signa of Applican/Contractor ate
OFFICE COPY