12990 . APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• - �UI LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING (pr6APPLICATION & PERMIT
AD RE55
O tC'lrK�ui Cr BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1 299
OWNER'S JJ PLAN CHECK VALIDATION
AME Q7y, ELECTRIC PERMIT FEE
P
CONTRACTORS UTLETS-SWITCHES
NAME -RECEP 10.00/1.00
i uc,rvo. LIGHTING FIXTURES 10,00/1.00
l.APPLIANCES-RESIDENTIAL 4.00 '-
�1! HON PANELS 10.00 Al DATE OF APPLICATION
ARCHlTffCT IPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
Lie.NO. SIGNS TRANS. 3.00
ARCH.OR ENG: SPECIAL CIRCUIT S.00 PER MIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE BCH. a.
ADDRESSDDRESS _
SERVICE CHANGE 0100 / /`' ;J
00 LICENSED CONTRACTORS DECLARATION / o
U w I hereby affirm that I am licensed under provisions of Chapter 9 f Q 7 ISSUANCE DATE
al Q at (commenting with Section 7000)of Divisionr of the mess and - BLD., ELECT. PLG. MECH.
F i Professions Co�n�dd///rrr���s l"Cove is in full •��
Z,OR T o License CSS Lie.Numb ❑ ❑ ❑
E2 t ! f-C°nlr°°t0 �- City of Cu ertino
at y f J
a ¢ OWNER.BUILDER DECLARATION� BUILDING PERMIT
A, Be w r-' REFER TO ORD INFORMATION
'x ;' y I hereby affirm that I am exempt from the Contractor's License MISC.-
ww0 ¢ Law for the following reason.(Sec.7031.5,Baonesoand Professions PERM IT ISSUANCE 10.00 VALUATION 5/FT.
w m Code:Any city or county which requires a permit to construct,alter, Q
¢ aQ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
u am G u requires the applicant for such permit to filen signed statement that TOTAL r' PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License //---
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the CL.f�2
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
M F the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ;� by any applicant for a permit subjects the applicant too civil penalty ALTER -WATER IEA.) 5.00
of not more than five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the Structure is not
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 on owner of
• property who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve GAS-EA.SVSTEM-1 6.00
mems 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.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im RES IND LNG PB Other
prove for pulp...(sale.). INDUSTRIgL WASTE INTER. 30.00
❑ 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-OVER 5(EA.) 1,00
Contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I om exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dote WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 - a
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certifn of Workers Compensation Insurance,or a certified
,Lab..
mpany_
Q ❑ Certified copy is hereby for Chad. � FIRE SPRINK ENERGY T-24
Ar. n I d w' 1 h ins action division. MISC.- REFER TO ORD.
Z p APPlicun �. - V ❑ N❑ Y ❑ N❑
~ a PERMIT ISSUANCE 10.00 BLOOD ZONE A.L.U.C.
LUCERTIFICATE OF EXEMPTION FROM WORKERS'
W COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
d O (This section need not be completed if lire permit is for one TOTAL Y❑ N❑ V ❑ N❑
=) Z hundred dollars($100)or It..)
U O I certify that in the performance of lire work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f- mil is issued,I shall not employ any person in any manner so as to
U became subject to the Workers'Compensation Laws of California.
0 a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT': If,after making this Certificate of Ex-
? emption,you should become subject to[be Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
f,) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
file perfomlance of the work for which this permit is issued(Sec. MICROFILM
Cf
3097,Civ. j17w/�� d// G 1/ ,A / HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Na _�L�i!.G_�Y""•t'
Lender's Address HEATI NG UN IT(OV E R 100,000 B.T.U.)9.50 ELECTRIC
• I certify that I have read this application and state[hat 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•= (H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COM1P Ova,100,000 STUI SEE FEE SCH, MECHANICAL
above-mentioned property lot inspection purposes.
(We) agree 4, .
and keep harmless the City of MISC.• REFER TO ORD.
ertino agaideals, costs and expenuS which PERMIT ISSUANCE - 10.00 CONST.TAX
me in any wad City in consequence of thegr ting of this ECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
ignatureo AUae
OFFICE COPY