8187 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT- �� .
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWN R' 1510PLAN CHECK VALIDATION
NAME PTY. ELECTRIC PERMIT FEE
• Horve
NAME R - Z
oNTRAcroUTLETS-SWITCHES-RECEP .00 C-
LIC.NO. LIGHTING FIXTURES
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 1D DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLANCHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ADDRESS ENG. 00 5.00 PERMIT VALE CATION
ZIP TEMP.METER OR POLE INS. 20.00 ,
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
FA SERVICE CHANGE �2 Q
� 0 2 LICENSED CON FRAC'I ORS DECLARATION TEMP.POLE - 30.00
Ix v I hereby affirm Ihat I am licensed under provisions of Chapter 9
ISSUANCE DATE
w a m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MEC .
F w z Professions Code,and my license is in full force and effect.
Z0 License Class Lie.Number
9 z w Dale Contractor
,F
E BUI DING RMIT
a w OWNER.BUILDER DECLARATION INFORMATION
K
;a y I hereby allinn l at I am exempt from the Contractor's License MISC.- REFER TO ORD vALunnoN
� u 0 4 I.E.In,the following mason.(Sec:7031.5,Yash nessand Professions PERMIT ISSUANCE
Code:Any city or county which requires u perm it to construct.alter,
SE rt ¢ 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- rE requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
I- zr
Law(Chapter 9(cum mencing with Section 7000)of Division 3 ofthe
e Business and Professions Cade)or that he is exempt therefrom and PTV. PLUMBING PERMIT FEE
r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES P C NSTR.
i3 $ by any applicant]or a permit subjects the applicant toacivil penalty ALTER-DRAIN& VENT-WATER (EA.) }�
of not more them five turreted doliars($500).1:
❑ I,as owner ut the property,or my employees with woges as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole eonipensutiun,will do the work,and the structure is not
intended or offered I'or sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractors License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5. SO.FT.FLOOR AREA TOTALACREAGE
• himself re through his own employees,provided that such im ilding
himselfms re Not through hiss or offered employees,
or provided
teat suhebudding GAS-EA.SYSTEM-1INC.40UTLETS 6.00
.r or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that lie did not build or inn- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
`i RES IND CON PB Other
p. for purpose of saople.). INDUSTRIAL WASTE INTER. 30.00
e ❑ ❑ ❑ ❑ ❑
j I as uwner of the property,am exclusively contracting with
/ li •J contract,),., to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'I'lie Contractor's Licmise Law does not apply
l,)an owner of Property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
on
clmcts for such projects with a contractorO licensed pursuant to
[lie Contractor's License Law, S EWE R-SANITARY-STO RM EA.200ft/10.00 TRACT NO. PARCEL NO,
O I am exempTuWer Sec ,B.&P,C.(HE this WATER HEATER W/VENT 6.00
ason
Owner Date 3T j WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'C M PENSATION DECLARATION WATER TREATING EQUIP. 5.00
I Hereby affirm that I have a wilco,of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sac.3500,Lab.C.).
policy No. Companyj
O Certified copy is hereby(�,i�r, 4_9 FIRE SPRINK ENERGY T]4
Z 2 19 Certified copy is Filed with the city inspection division. MISC.- -REFER TO ORD.
0 Applicant Y❑ N❑ Y ❑ N❑
CCN CF-R'I'IPICCI'17 OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 1 FLOOD ZONE A.L.u.O.
W COWINSAT1ON INSURANCE PLG.CONTR. LIC.NO. PLG. 12
0- 0( This action need not be cumpleled it the permit is for one TOTAL Y ElN❑ Y E] ❑
N
hundred dollars(S I00),)r I,,.)
U 0 1 certify that in the performance of the work for which this'per- GTY MECHANICAL PERMIT FEE FEE SUMMARY
J_ F- mit is issued, I shall not employ any person in any manner so as to
U become subject to The Workers'Compensation Laws of California.
n Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} Ma NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z eniption,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 PCrnit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONST'RUC'TION LI?NDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance o1the work for which this permit is issued(Sec. MICROFILM
3097.CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name d Imo- HEATING UN IT 100,000 B.T.U.)9.50 /
' Lender's Address W-/� ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 1.14
information n correct. 1 agree to comply with all city and county PLUMBING n/ 1
informatio and state laws relating m building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise 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, indemnify and keep harmless the City of Misc.- REFER TO ORD.
Cupertinagainst liabilities,judgments, costs and expenses which ONST.TAX
may io n any w, accrue again 'd C'y in consequence of the PERMIT ISSUANCE / 10
grantingof[ CtmiL MECH.CONT. LIC.NO. M H.
TOTAL / TOTAL
Sign rAEryf/Cyffiryffr Date
INSPECTOR COPY
I