11287 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATIONPERMIT NUMBER
BUILDING - APPLICATION & PERMIT ':
ADDRESS 19
5 G�..� .DING-ELECTRICAL-PLUMBING-MECHANICAL
.9 a12
OWNER'S PLAN CHECK VALIDATION
N QTY. ELECTRIC PERMIT FEE
O M PHONE ,J
A ACTOR'S UTLETS-SWITCHES-RECEP 10.00/1.00 pr -
W LIC.NO.5 70ffg
IXTURES 10.00/1.00 U
o RAc7oR's -RESIDENTIAL 4.00 P '---
DRESS c
mdeA PHONE �aJ 10.00 DATE OF APPLICATIONARCH ECT a - ER 200 AMB) 20.00PLAN CHECK FEE PC.NO.
ERENGINEERLlc.rvo. S. . 3.00ARCH.ER EN CUIT S.QQPERMIT VALI DATION
ADDRESS
ZIP M . R OR POLE INS. 20.00
APPLICANT'S - MOTORS - SEE FEE SCH.
ADDREss
py SERVICE CHANGE 20.00 /0 .
D O o LICENSED CONTRACTORS DECLARATION /�7
- C
u v I hereby affirm that P am licensed under provisions of Chapter 9 ISSUANCE DATE
w¢i (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
D i Professions Co nd y license is in full f A�y��
z o p- License Cass nd Lic.Numb r ❑ 'a"6 ❑
Q L L w Dale Cont,
El
P
y BUILDING PERMIT
S rc w u OWNIi R-BUILDER UECLA ATION INFORMATION
R: 01 hereby affirm that I am exempt from the Contractor's License MISC. REFER TO ORD
3:u
FUOJ Law for the following reason.(Sec.7031.5,BusinessandProfessions PERMIT ISSUA CE ' 10.00 VALUATION $/FT.
Code:Any city or con my which requires a permit to construct,alter, 6
w
rt ¢s- improve,demolish,or repair any structure,prior to its issuance,also EQ CONTR, LIC.NO. ELEC.
i O LL requires the applicant for such permit t0 file a signed statement the TOTAL 3 C& PERMIT TO
w9 a he is licensed pursuant to the provisions of the Contractor's License
r2 > Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe 1 1 If -Z,
aBusiness and Professions Code)or that he is exemprtherefrom and QTY. PLUMBING PERMIT FEE -
at 1- tire basisfor the alleged exemption.Any violation ofbeclion 7031.5 STORIES TYPE CONSTR.
d ; by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ 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 Low does not apply to an owner of
• property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 50.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
emote are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS, 6.00
or
improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2,00
builder will have lire burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB oma,
❑ I,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply _
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft 10.00
the Contractors License Law. / TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00 -
Mason
Owner - Date WATER SYSTEM 5.00
- ACC.GATE ACC FILE NO,
WORKERS'COMPIINSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate'ofconsent to self-insure,
or a certificate of Workers'Compensation Insurance,or a car fieri ZONING ENG.SITE N0.
copy there (Sec. 0p Lab.C.I.- -
I'olicYN�116mpanY
Q ❑ Ce ifie copy is hereby furnished. FIRE SPR INK ENERGY F24
Z Z' a--Ce d co is filed itq h the city erJlhection division. MISC.- REFER TO ORD. [:] ❑ ❑ ❑
O Applicant �{be c<I/ YN V N
va
CER EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 •FLOOD ZONE A.L.U.C.
LU IFICATE -
Ill _ COMPENSATION INSURANCE PLG.CDNTR, LIC.NO. PLG.
CL 0 (This section need not be completed if the permit Is for one TOTAL Y❑ N❑ Y❑ N❑
0 Z hundred dollars($100)or less)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL Emil is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
O old. Uale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z 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
V 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 10,000GRM.I 6.00 SEISMIC FEE
I hereby affon 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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILMS
3097,Civ.CJ.'
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I 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'representalives 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.
Cupertinagainsl,Babililies,judgments, costs and expenses which - CONST.TAX
may in any y accrue against said City in consequence of the PERMIT ISSUANCE 10.00
r ting of permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
nature of Ap tlContractor Date
OFFICE COPY