13407 (2) 1Y�////1 APPLICANT TO FILL IN INFOR TION WITHIN RED LINES - USE B< POINT PEN ONLY -
Y , BUJLDING PRO TIDENT]FICATI PERMIT NUMBER
/ Is ILOING APPLICATION & PERMIT
A° .BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 13407
rIONNIM B PLAN CHECK VALIDATION
MARCHITECT '
�I Y. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP 10.00/1.00
uc.N LIGHTING FIXTURES 10.00/1.00
APPLIANCES-RESIDENTIAL 4.00
PANELS 10,00 DATE OF APPLICATION
PANELS(OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
On
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT S.00 PERMIT VALIDATION
AOORESs
ZIP TEMP. METER OR POLE INS. 20.00
A CA MOTORS SEE FEE SCH.
E
G SERVICE CHANGE 20,00
w o o LICENSED CONTRAC ORS DECLARATION
¢u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANC DATE _
vHi Q H (Commencing with Sec�tiop 7000)of Division 3 of the Business a BLDG. -ELECT. I P G)'. 'MECH.
H h z Profession`Co nd-flil license is in full force 'PARI/l
Z i m W License ass �lJ Lic.Ni
l'L V - n ❑
Date Con=ructor _ is Ptr'
s - BUILDING' RMIT
Ixw u OWNER-BUILDER )ECLAR 'I ON INFORMATION
01, MISC.- REFER TO ORD
L a. N I hereby affirm that I am exempt from the Contractor's License
uo¢ Law for the following reason. 7031.5,Business and Professions pERM1T ISSUANCE 10.00 VAwATION E/FT.
' E �,�%� Code:Any city or county which requireso permit toconstnecl,almr,
2 ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o u requires the applicant for such permit to file a signed statement that TOTAL RM
w$ he is licensed pursuant to the provisions of the Contractor's License �`r/y�
�¢ � Law.(Chapter 9(commencing wit h Section 7000)of Division 3 oft he ! �/1
¢ Business and Professions Code)or that he isexempt therefrom and CITY. PLUMBING PERMIT FEE tt--��
¢ Is- the basis for the alleged exemption.Any violation of5eclion 7031.5 STORIES T STR.
by any applicant for a permit subjects(lie applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(55000.):
❑ 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 an owner of
property who builds or improves=hereon,and who does Such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTALACREAGE
hinnsell'or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or am. BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omar
O 1,as owner of the properly,ann 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 Low does not apply
to an owner of property who builds or improves=hereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a convactons)licensed pursuant to SEWER-SANITARY-STORM EA.200itI10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec..,B,&P,C.for this WATER HEATER W/VENT 6.00
reason
Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
W R ZF,ts'COh PF-NSATION OfiCLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to self-instim, ZONING ENG.SITE NO.
or a certificate of Workers'Com vat i Ins r:n r cr=if
I '
cop,thereof(Sec.3500,LeM1.CJ.
Policy No. Compan _
O O CeNiliedco is here mid, •. FIRE SPRINK ENERGY T.24
❑ Certif eo i f with (h city inspection division. MISC.- REFER TO ORD.
Z ZO Applicant Y❑ N❑ Y ❑ N❑
CCy CERTIFI 'A1 1:OP'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU':� COMPENSATION INSURANCE INSURANCE PLG.CONTR. - LIC.NO. PLG,
CL 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y [3N❑
hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
OUbecome subject to the Wotkers'Connpmnsation Luwso fCalifornia.
G. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
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=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY . AIR HANDLING UNIT(OVERd6p000F.M.) 6.00 - SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which(his permit is issued(Sec. MICROFILM
3097,CN.C.). HEATING UNIT(TO 000,000 B?T.O.P 8.00
Linder',Name H EATI N G U N IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the uhove VENTILATION FAN'�(SINGLE)ni)jtl0 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relining to building construction, and 7 BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-menOk
for inspection purposes,
(We) ademnify and keep harmless the City of MISC.- REFER TO ORD.Cupertinos,judgments, casts and expenses which ONST.TAXin against said City in connsequence of(he PERMIT ISSUANCE1000gra d /�� ME .CONT. LIC.NO. MECH.(/ i /I T° i TOTAL
Signa to of Applicant/Contractor Date
OFF IC COPY