10257 (2) APPLICANT TO FILL IN INFORMATION RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PR ECT IDENTI FIC /
eul c APPLICATION & PE10T
_
A .( 'D NG -ELECTRICAL-PLUMBING-MECHANICAL 1025
OW R' PLAN CHECK VALIDATION
"AME QTY. ELECTRIC PERMIT FEE
oNE
vAMT T RS A ' 7NO UTLETS-SWITCHES-RECEP 10.00/1.00
/[,nuc.No. �7 LIGHTING FIXTURES 10.00/1.00
eooT' ARS /' PPLIANCES-RESIDENTIAL 4.00
UPNON PANELS 10.00 DATE OF APPLICATION
A CNITECT
-
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO SIGNS TRANS. 3.00
ARCH.
ss ENG' - SPECIAL CIRCUIT 5.00 - PERPII+T VALIDATION
AD nv EMP. METER OR POLE INS. 20.00
AYP4CANT'a 1 MOTORS SEE FEE SCH. JAN
LI 1 A
• ES x1MIY 1 t 9®L
SERVICE CHANGE 20.00
ca o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of 96oe -
¢o u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE'
rn,w foonmencing with 5 tion 7000)of Division 3 of the Business' d BLDG. ELECT. PLG. MECH
F 0 Z Professions Code,a my/�erise is in full force ❑ ❑ ❑
Z O m- Licorice lass_ _!// Lic.Number
q Z R_ Date zu Contractor_
Q y E J
cr x a OWNER DER DECLARATION BUILDING PERMIT
d u INFORMATION
w ; N 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL o j Law for the following reason.(Sec.7031.5,Business and Professions VALUATION S/FT.
H - PERMIT ISSUANCE 10.00
,40 Code:Any city or county which mquiresa permit feconslruct,uher,
a ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR LIC.N0. ELEC.
at 0O ¢ requires the applicant for such permit to file a signed statement tlwt TOTAL
u w m he is licensed pureuanf,to the provisions ol'the Contractor's License PERMIT TO �s
I- ZQ
Law(Chapter 9(commencing with Suction 7000)of Division 3 of the p,l/ 1
E o Business and 1'rufeviens Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ry" VV 1 /
¢ H o the basis lot the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for it permit subjects Lie applicant o a civil penuhy ALTER-DRAIN -WATER lEA.15:00
of not more than five Iwndred dollors(S500).1:
O I,as owner of file property,or my employees with wagcx as BACK F LOW PROTECT. DEV ICE 4.00 ocC.GROUP RES.urvtTS
their role compensation,will do the work,and me structure a not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CO_ND. 5.00
Code:'I'1¢Contractors License Low docs not apply to an owner of
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 so.FT.aooR AREA TOTAL ACREAGE
S himself re through his own employees,provided that such improve-
OfIT ImprovemNot ent
is sold withinron for year .l completion,
the the o Jing GAS-EA.SVSTEM-11NC.40UTLETS 6.00
Of lder will
have
is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
provebuilder will have the burden of proving thin he did not build nr im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ L m owner or the mnstraproperty,he exclusively.7044,lins with S P F-1 11
licenvd contractors to vomtruct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO,
r
ofessions Code:The Contractor's License Law docs not apply
ayPn owns'of propery 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.
❑ l and cxsmpf under Scc. - ,B.&P.C.for this WATER HEATER W/VENT 6.00
rcasun
Owner Date WATER SYSTEM 5.00 - ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'IION DECLARATION WATER TREATING EQUIP, 5.00
1 hsrcby affirm thot I have a efoificots of comcnt to ell-insure,
or a cert II scat•of WorkCt2 Compensation Incur •,or a ceulIh,d ZONING ENG.SITE NO.
Copy they• 1 ).
Policy N' I !t
O ❑ l'rtified enpy irh vrri'
',`CIC FIRE SPRINK ENERGY T 24
Z 2 Cert if sed c p, is 9$d the e - specfimt division. MISC.- REFER TO ORD.
F p IICAet v N v N
N CER'1'114CA'I' 17 EXEMPTION PROM WORKERS• PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
W CO, PF,NSATION INSURANCE PLG CONTR. LIC.NO. PLG.
d ❑ ❑ ❑ ❑
0 (This section need not be completed if the permit is for one TOTAL Y N v N
:D 2 hundred dell ars(S 100)or les")
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
manner LL 1- mit is issued.I shall not employ any person in any aner so as to
O W becomesuhject to the Workers Compensation Laws of California.
M Dat4 Applicant BUILDING
>_ w NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F ? 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 10=GF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SMC.F.M.) 6.00 .� SEISMIC FEE
I hcrehy affirm that mere is a construction Icnding agency]Or EXHAUST HOOD (WITH DUCT) 5.0
the performance of the work for which this permit is issued(See CROFILM
3097,Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00
Louder',Name H EATING UN IT(OVER 100.000 B.T.U.)9.50
Lender;Na...0 E CTRIC
I certify that I have read this application and stat,shut the above VENTILATION FAN (SINGLE) 4.091
information n correct. I agree to comply with all c city and count BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
hereby es and erre laws relating to building construction, and
hereby enti orid representatives ec this city to enter upon file BOILER-COMP (Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree tWavc, mnify and keep harmlessthe City of MISC.- REFER TO ORD.
Cupertinoagaijudgments, casts and expenses which ONST.TAX
may in any aailot Said City in consequenec of the P RMIT IS ANCE 10.00 MECH. NT. LIC.NO. MECH.
Of TOTAL TOTAL
am
no
of Apphcan UCoir nlc Date
OFFICE COPY