11681 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT 1 DENT[FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 11681.
OWNE 'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
vuONd
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME `
ND25b11 y72 LIGHTING FIXTURES 10.00/1.00 ,
CONTH OR's APPLIANCES-RESIDENTIAL 4.00
ADDRESS
C�\ NEI PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.L.NO.
OR
ENGINEER
uc;No. ISIGNS TRANS. 3.00
ARCH.
DD Ess eeG. SPECIALCIRCUIT 5.OD PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH. -
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION 1 I
IS u C, I hereby affirm that 1 am licensed under provisions of Chapter 9 'NCE DATE
N a w (commencing with Section 7000)Of Division 3 of the Business and L PLO. MEC
11
H H z Professions, e�yl Se is in full fort• n ejJ'c. J�-
0 o m License ss _ Lic.Number ❑ El
9l2 w Date Contractor IIP
a ,2 , - BUILDING PERMIT
¢ ¢ w t4i _ OWNER-BUILDER DECLARATION INFORMATION
w3 LL I- I hereby affirm that 1 am exempt from the Contractors License MISC.- REFER TO ORD
F u o 4 Law for the following reason.(Sec.7031.5,Business and ProfessionsPERMIT ISSUANCE 10.00 VALUATION J/FT.
,40 Code:Anycity orcounty which requires a permit to construct,alter,
atoe improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
to D ¢ relishes the applicant for such permit to IIIe it signed Statement that TOTAL MITT
A w m a- he is licensed pursuant to the provisions of the Contractor's License r
H z V Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe PE
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
f i D
¢ F $ the basis for the alleged exemption.Any violation oro a cion malty STORIES TYPE CONSTR.
a ; by any applicant fora permit subjects the applicant loacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 5.00
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 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE.
himself Or through his own employees,provided that such improve-
mentsare not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.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 the burden of proving that he did not build or im- s BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00 IND CON PB Othe,
❑ I,as owner of the property,am 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 Law does 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 contractor(s)licensed pursuant to
rhe Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ I am exempt under Sec. .B.&P.0 for His WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC FILE N0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm 0mt I have a certificate oft,...Cut to self-insure,
or a certificate of Workers'Compensation Insurance,or it certified ZONING ENG.SITE NO.
copy then Sec. 800,Lab.C.).
Policy No. pzmpenylf2LiTl
0 ❑ Certified copy isherchyfurnished. FIRESPRINK ENERGY T-24
Z 2 Certifle�f�qp fie w�'th the city inspection division.
O Cant_ /._:LkL� TI Misc.- REFER TO ORD. YE] N❑ Y ❑ N
~ va PERMIT ISSUANCE 10.00
� CIiRTI PICC04E SA'i[OTINS FROM WORK IiRS' FLOOD ZONE A.L.U.C.
W >_ COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG,
d o ('Phis section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z) 2 hunched dollars($100)or Iess.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
O Ubecome subject to the Workers'Compensation Laws of California.
CL Dat° Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} Do NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F 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
C„) 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 1010WC.RM.) 6.00 SEISMIC FEE
I hereby affirm that there is a dunslruction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name - HEATI NG UNIT 100,000 B.T.U.)9,50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 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-mentioned property for inspection purposes,
(We) agree to save, inde2W4
and keep It2rmless the City of MISC.- R ER ORD.
Cupertinorlr'�pg�ins[ liabilities, entb costs and expenses which PERMIT IS AN E 10.00 CONST.TAX
MECH
miry 'n a way accrue a wirl City in consequcnoe of the '�/)
gran ng this Permit MECH.CONT. . O. TOTAL/1 �/ r+
Sie of Applicant ou roc' au~ TOTAL
OFFICE COPY