1010 (2) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL. POINT PEN ONLY . A
BUILDING PROJECT I DENTI FICATI ONPERMIT NUM
MEI
BUILDING APPLICATION & PERMIT 1010
/C t,
)f!L&('�f BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S v - p. CHECK VALIDATION
"AMEa J C+( /}R�C 7s��'//� OTY , ELECTRIC PERMIT r FEE
J .,
CONTRACTORS
NAME UTLETS-SWITCHES-RECEP 5.00/1,00
NAME
LIC.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'SPPLIANCES-RESIDENTIAL 4,DO
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT 6.00 PLAN CHECK FEE P.C.NO.
OR SIGNS
ENGINEER u 3.00
C.No. - SIGNS TRANS.
ADDRESS ENG. S PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 /
0 0 o LICENSED CONTRACTORS DECLARATION
uU I hereby affirm that 1 am licensed under provisions of Chapter 9 ?t�.E DATE
as 'sI (commencing with Section 7000)of Division 3 of the Business and
BLDG. ELECT. PLG. MECH.
r N i Professions Code,and my license is in full force and effect. ® ❑ ❑ ❑
o w- License Class Lic.Number
L w Date Contractor
se¢ er OWNER-BUILDER DECLARATION BUILDING PERMIT0 wTZ..
a w u ::z INFORMATIONa.�-.
3 u I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u O Law for the following reason.(Sec.7031.5.Businessand Professions VALUATION S/FT. ^
Code:Any city or county whichrequiresa permit toconstruct.alter, PERMIT ISSUANCE 6.00 7"
Sc improve,demolish,or repair any structure.prior to its issuance.also ELEC.CONTR. NIL.NO. ELEC. /
A.O IS requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A.
he is licensed pursuant to the provisions of the Contractor's License �1
_ ia Law(Chapter 9(commencingwith Section 7000)ofDivision 3 ofthe sr 'yL:r'+? 7' r3-.t{qPM^ Opel(
Business and Professions Code)or that he is exempt therefrom and OTY s 5 d' .PLUMBING PERMIT-.•- .P't4 s FEE ;t
D a s.,iP STORIES TYPE CONSTR,
X I- the basis for the alleged exemption.Any violation of5eaion 7031 5 P ..>, 1 n• .. •��'-r N'x 4,..5
i ; ,. by any applicant for a permit subjects the applicant to a civil penally gLTER-DRAIN -WATER (EA.) 4.00
of not mote than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as IBACK FLOW PROTECT,DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure D not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-F ND. 4.00
Code:The Contractor's License Law does not apply(o an owner of
property who builds or improves thereon,and who does Such work FIXTURE - S, MAIT 4.DO s0.FT,FLOOR AREA TOTAL ACREAGE
himself or through his awn employees,provided(ha(such improve-
GAS-EA.SV •1 I LETS 4,00
meets are not intended or offered for Sale.If,however,the building
or improvement is sold within one year of completion,the owner-
builder will have the burden orproving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
P B RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASI R. 20.00
❑ as owner of the properly, exclusively contracting with El 1:1 1:1 1:1 1:1
to
contractors tococonstruct thehe project(Sec. 7044.Business LAWN SPRINKLE S C 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractorto licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ I am exempt under Sec. .B.AP.C.far this WATER HEATER W/VENT 4.00
re"
l
Data - - 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 eenleaf to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T24
Z
❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
O: H CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG.
1 Cl (This section need not he completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z hundred dollars IS 100)or less.l - / _ -
U O 1 certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT - FEE T FEE SUMMARV;g."�"-__
LL I- mi(is issued,I shall not employ any person in any manner so as to - -
U become subject to the Workers Compensation Laws of California, �7 r l
O w BUILDING .�
u Dam APPLICANT:
I ALTER OR ADD TO MECH. ,4.00 70
} m NOTICE TO APPLICANT: If,after making this Certificate sa Ex
F Z emvision you should became subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions the Labor Code, you must forthwith comply with. FEE
f..1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,0OD C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M) 5.00 SEISMIC FEE rs Z
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT ITO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
1 certify that I have read this application and state Ilia,the above VENTILATION FAN (SINGLE) 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-CON?(3 H,P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agr to save, indemnify and keep harmless the City'of Misc.- REFER TO ORD.
Cupertin g est liabilities,judgments cost nd expenses which CONST.TAX
&h'"Spermat
accrugalnst sai i(y consequence of[he PERMIT ISSUANCE 3.00 G MELH.CONI. LIC.NO. MECN.! TOTALpp'--ant1Co Nor Date f 1 t•% "P.r"" "'tit-f
OFFICE COPY