2668 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATIO PERMITN MBE ���
BI o c l / d APPLICATION & PERMIT
Ao sa r 7 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
II
OwNER'S /` I / PLAN CH ECK VA LIGATION
CITY. ELECTRIC PERMIT FEE
. /I�IIrJA/�O«/ P CCCsss
CONT CTORs UTLETS-SWITCHES-RECEP 5.00/1.00
NAM M /
SrO LIGHTING FIXTURES 5.00/1.00
noNTR99cions / PPLIANCES-RESIDENTIAL 4.00
ADDRFa�/ �� /�� /�/ /
II�i�s 6 v,G�vA PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 5,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG' SPECIAL CI RCU IT 5.00 PERMIT VALIDATION
ADDRESS
zIP EMP.METER OR POLE INS. 15.00
AvvucANr's IMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 JQ/vi/
o o LIC17NSIi1)CONTRACTORS DECLARATION
w I hereby aft'inn that I ant licensed under provisions of Chapter 9 ISSUANCE DATE
y a y Imntmencing with}}eetk 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r h z Professions CodC,&d mteu is in full fitrePlt)Jtpe ❑ ❑ ❑
Z, D w - License CLt s hie.Nunhbe JG2.7U7�'fZ / ��
o Dalc���7-��Contractor BUILDING PERMIT
w u OWNI;R-EUII.DI!R DECLARATION INFORMATION
w3 LL I hereby affirm that I ant uxentpl from the Contractor's License MISC.- REFER TO ORD
u0 J Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE j'�L ATIOnI, S/FT.
t - 0 Code:Any city or county which ret,iresa permit to construct.alter,fe
R ¢ 20 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
- DLL requires the applicant for such permit to file o signed statement that TOTAL PERMIT TO
n wes se he is licensed pursuant to the provisions of the Conlntetor's License
F z a Law,(Chapter 9(commencing with Section 70001 of Division 3 of the 2
f 4 D Business and Professions Code)or that he is exempt IherrfRm and QTY. PLUMBING PERMIT FEE
H p the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR,
i ;m by any applicant fora permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER IEA.) 4.00
of not mare than five hundred dollars(S500).): -Cityof Cuperti 10
O 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their We 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. 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 .FFLOOR AREA TOTAL ACREAGE
• himself or Ihwn rough his oemployees,provided that such iwT
mprove-
mentsare not intended oroffered for sale.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 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON PB Omer
prove for purpose ofsalc.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
❑. 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. 5.00 ASSESSORS PARCEL NO.
and Professions Code: rhe Contractor's License Law dues not apply
to an owner 01 Property who builds or inmroves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such proleels with a cont aclar(1)licensed pursuant to
the ContraclorFLiccme Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
Cl Ia...cxcmptunder5• ,B.&RC.for this WATER HEATER W/VENT 4.00 -
1Y,al m
Date _owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
W'ORKEI 'CO'NUIENSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirnt that I have a¢r IbCatC ufconscnl to sCl Ginsure. ZONING ENG.SITE NO.
or n til icalc f WkoyrkAu/cLc'�hCom�pcnsw�i ao�n/lr,tupncc,or a cc rt,l,ud
copy ) v�ll/n( 'C//
Iblic I ally
Q ❑ 1
cJ c y I hy�ryyhy fhnnishc FIRE SPRINK ENERGY L24
Z Z Cartil'icJ �h iy/jhh altl y{�/� MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
APPlicxnl �i LL-�l_/![T_ v N v N
F" v0-iPERMIT ISSUANCE - 6.00 FLOOD ZONE A,L.U.C.
� - CF-R'I'IFICA rr OF EXEMPI'ION FROM CORKERS'
LJ > COMPI:NSA'I'ION INSURANCE PLG.CONTR. LIC.No. PLG,
CL O This section need not be completed it the permit is for one TOTAL v❑ N❑ v F] "❑
=) 2 hundred dollars(4100)or]uNs I
L) O I certify that in the perf'orniance of the work for which this Per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,1 shall not employ any person i any reamer so as to
O w become subject to the W'orkers'Compc 'Y Laws of California BUILDING
Date Applicant- ALTER OR ADD TO MECH. 4.00
} N NOTICE TO APPLICANT: If,ate ing this Certificate of Ex- SL
? eruption,you should become sub 10 the Workers'Compensation APPLIANCE 4.00 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 10=C.F VL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE 5
'2
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which t permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ C.1.
Lender's Name HEATING UN IT(OVER 100,000 B.T.U,)7.50 ELECTRIC
Lender's Address ...
I certify thus 1 have read Ih' kation and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct I a c to comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING :
ordinances and state la . relating to building construction, and
hereby authorise representatives of this city to enter upon the BOILER-COMP love,100,000BTUISEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes,
(We) agree to save, indenmify and keep harmless the City of ICo
perti o ugvinsI lie h'A
dgmentsosis J expnses which CONSTTAX
my any w�ty ust said City i nhsequcnre of the ISSUANCE 3.00Bon t CmlMECH. LIC.No. MECH.
�7� TOTAL TOTAL
Signature o': p lic:m tor Date
OFFICE COPY