8168 r APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATIONPERMIT NUMBER
no'lia["Ss APPLICATION"& PERMIT
6� ' BUILDING - ELECTRICAL-PLUMBING'-MECHANICAL7. 7 8168
N r PLAN CHECK VALIDATION
..l E 1 ` /' QTY. ELECTRIC PERMIT FEE
• f SCOL KL.r¢/!� 'GHONE Z
coNTRAcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
uc.NO. E LIGHTING FIXTURES 10.00/1.00
ADDRESS APPLIANCES-RESIDENTIAL 4.00
NONE i PANELS 10.00 DATE OF APPLICATION
ORCNIiELT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.-NO
OR
NG EER
� LIC.NO. SIGNS TRANS. 3.00
A C .0 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
SQla�01l� a,�v�a. EMP.METER-OR POLE INS. 20,00 !
AUOR ss MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
o o LICCNSFiD CONTRACTORS DECLARA7 N TEMP.POLE 30.00
a v 1 Inecty affirm that I am licensed under provisions of Chapter 9 j:, ISSUAN E DATE
(commencing with Section7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
y zo 1'Rdcxxions Code,and my license is in •'full fore nd effect. I-II t-I
z o - 1-Icemse Class'_v' Lic.Numher
0 m Date 1,
�---Contrudor
`�� D-' BUILDING PERMIT
nt w OWNIi R-BUILDER DGCLA A` .. INFORMATION
X o ' y 1 hereby affirm that 1`am exempt from the Cnntmetor's License MISC.- y REFER TO ORD
LLVALUATION $/FT..
oa Law fortheFollowing
ounty,a(Sec.703L5,Businessand Professions -PERMIT ISS ANCE 1DD0
� - CodesAny city or county which requiresapermit to construct.alter, ..
w � ao improve'danolish,or repair any structure.prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
o. w m BE requires the applicant for such permit to file a signed statement that TOTAL 171 'LJ
he is licensed pursuant to the provisions of tire Contractor's License
i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and QTY. � PLUMBING PERMIT FEE
¢ H G the basis for the alleged exemption.Any violation u(Section 7031.5 STORIES TYPE CONSTR.
5,: by by any applicant for a permit subjects the applicant l0 a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
y of not ,are than five hundred dollars(55001.): S
❑'`I;as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and lire structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 '
Godo:'I'Im.C"mractor.'s License Law does not apply to an owner of.
)perty who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himselfor through his own employees,provided that such improve-
reentsarenot intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 yC
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 200 OO
builder will have the burden of proving that h - . - . .
e did not build im- BUILDING USE
prove for purpose of sale.). RES IND CON PB Ommn
❑ 1,as owner of the property, INDUSTRIAL WASTE INTER. 30.00 ❑ El 13 E
p p y.he exclusively 27044. u with
3 limensedcontractorstoconstructthe project Law
Business LAWN SPRINKLERS-1INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
.t to Professions Code The Contractor's License Law Jues.and who
man owner of properly who builds or improves Thereon,and who. LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contractons)licensed pursuant to - SEWER-SANITARY-STORM EA.200ft/10.00
's the Contractor'suLicense Law. TRACT NO, PARCEL NO.
.• l`. ❑ lmcxcmptunder Sec. ,EAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 r
•z-.L ACG DATE -ACC-FILE NO.
WORK ERS'COMPENSATION DECLA RATION WATER TR TING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING
or u er,lherue of m
Workers'Copensation.Insumnee,or a certified ENG.SITE NO.
copy thereof(See.3800,Lab.C.). 4',,. L-
0
oi
Policy No. Company�a�q
O C3Cert t,,d copy is hereby fu{nidi, FIRE SPRtNK ENERGY T-24
Z pf] Certified copy-is filed with the city it nc 'om divisi
O Apttficant MISC.- REFER TO ORD. Y [] N❑ YE] NE]
'~ PERMIT ISSUANCE 10.00
LU CfiRl'IPICA MPENSAIi10= PR ,IW lt�WtSI FLOOD ZONE A.L.U.C.
_ W COM PENS AI ION Inked Iif the o PLG.CONTR. LIC.NO. PLT YC] NE] YD N[j
/ Z (This section S10 not be completed it the permit is for one TOTAL IO
hundred dollen IS 100)or Icss.) .
U O 1 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 tiny manner so as to
O become subject to the Workers'Compensation[Laws of Gdilornia.
y Date - Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO AVP L ICA N'I': IL after making this Certificate of Ex-
Z emplion,you should became subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must flovith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION L17NDING AGGNCY AIR HANDLING UNITIOVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction 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.I HEATING UNIT(TO 100,000 B.T.U.) 8.00
S- Lead T's Namc
Lender's Aedre.e # HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Sr��CasAerlffi5
I certify that 1 have read t Is app canon and slide that the above VENTILATIO FAN (SINGLE) 4.00
information n correct I agree ti comply wuh all city and county PLUMBING
Ordinances and state laws relating To building construction. and BOILER- I3 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 !J'O
above-mentioned properly for inspection purposes.
J
(
( agree to save, indemnify and keep hornless the City of MISC.- REFER TO ORD.v Cupertieni no against liabilities,judgmads, costs and expenses which pERMIT ISSUANCE 1D.00 CONST.TAX -
may in any way accrue up I t said City int consequence of the �--�
grant of th ', emriL �/ MECH.CONT. LIG NO. MECH.
�_ Ls - TOTAL TOTAL J
Sig uturc o p I a on tractor Date
INSPECTOR COPY
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