4228 (2) f APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION &'PERMIT 4228
ADDRESS
ZZZ3l e1upwov P�,D- G(/P. BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S .1-�I PLAN CHECK VALIDATION
NAME /.�}f(� Sr CITY. ELECTRIC PERMIT FEE D -S
`t .' PHONE (/J'IDIS /3/ V
CONTRACTORS
rv4mE UTLETS-SWITCHES=RECEP 5.00/1.00
IV LIC.No, LIGHTING FIXTURES 5.00/1.00 •� 3 S ! "'!
CONTRAS OGRESops
AAPPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OT7
SIGNS TRANS. 3.00
ARCR gp4Ng - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
DOREss "
3y IJ lyT 3 vvdos� zIP J��Z EMP.METER OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE SCH.AD DRESS
27j�..?/7 � T 1 V, �� SERVICE CHAN - 10.00 U
M o - LICENSED CONTRACTORS DECLARATION
<v 1 hereby affirm that I am licensed under provisions of Chapter 9FEB 8 i984 ISSUANCE DATE
w <w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H H z Professions Code,and my license is in full force and effect. /
o 0 m o License Class Lia Number
Date Contractor City of CupQrtlnQ
t BUIUDING IT
M ¢ w OWNER-BUILDER DECLARATION INPO RMA ION
woA MISC.- REFER TO ORD
3 LL w I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
FU0< Law for the following reason(Sec.703 L5,Business and Professions PERMIT ISSUANCE 6.00 600
Code:Any city or county which requiresa permit mconstruet,alien
Qp¢0 improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. C
G M requires the applicant for such permit to file a signed statement that TOTAL 21.J P MI TO
u w$ he is licensed pursuant to the provisions of the Contractor's License
Hii Law(Chapter 9(commencing with Section 7000)of Division 3 of the
f 4 o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
ar H the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CO STP.
r,. 3 by any applicant for a permit subjects the applicant to a civil penalty .ALTER-DRAIN -WATER (EA.) 4.00
.I
of not more than five hundred dollars(S500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 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. 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 00 SO.FT.FLOOR ADEA TOTAL ACREAGE
himself or through his awn employees,provided that such improve- ,
-EA.SYSTEM-1 •4.00
mesare not intended or offered for sale,If,however,the building GAS
nt
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) .1.00 'BUILDING E
builder will have the burden of proving that he did not build or im- S IND CON PB Gone,
potfor purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
PD I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construe the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5,00ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Low does not apply _
to an owner of property who builds or improves thereon,and who iLAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for Such projects with a contractons)licensed pursuant to
the Contractor's License Law. SEWER SAN ITARY-STORM EA.200ft/8.00 TRACT PARCELNO.
❑ lamexcmpt under ec .,BAP.C.for this WATER HEATERW/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP- 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3804 Lab.C.L -
Policy No. Company p
Q ❑ Certified copy is hereby furnished. C FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with. the city inspection division. .- (IDD ORD.
O Applicant - MISC.- Y ❑ N❑ Y ❑ N❑.
'Fy
CERTIFICATE OF F,XEMP770N FROM WORKERS' PERMIT ISSUANCE 6.00 Qd FLOOD ZONE A.L.U.C.
� -
LU COMPENSATION INSURANCE PLO.CONTR. LIC.NO, PLO. Y[:] N❑ Y [:] N❑
CL O (This section need not be completed if the permit is for one TOTAL
Z) Z hundred dollar,($100)or less.)
C3 0 I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,1 shall not employ any person in any manner so as to
OW become subject to the Workers Compensation Laws of California. BUILDING w
[late Applicant ALTER OR ADD TO MECH. 4.00 /
} ti NOTICE TO APPLICANT: If,after making this Ccrt i(icate of Ex-
2 emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 t PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMICIFEE
I hereby affirm that there is a construction lending agency 1'or EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.001MICROFILM
3097,Civ C.). ,
Lender's Name HEATING UNIT(OV OO OO B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and slate that the above VENTILATION FA ( I ) 3.00
information is correct. I agree to comply with all city and county PLUMBING
� ordinances and state laws relating to building construction, and BOILER-COMP or 100,000 B.T.U.) 4.00
. hereby authorim representatives of this city to enter upon the, BOILER-COMP IOver 11,00 T J EFEE SCH. MECHANICAL
above-mentioned property for inspection purposes. /
(We) agree to save, demnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertin agoin01 iiahili Ins,judgments, costs and expenses which IRO 3.00 QQ CONST.TAX
may i y w y r ag ' t said City in consequence of the - PERMIT ISSUAN E
gran p � MECH.CONT. LIC NO. MECH. TOTAL I
OTAL
S 4 re of A i nt/ n actor Due y
OFFICE DOPY '