09716 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY"
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING SOT APPLICATION & PERMIT
/DDRE09716
55
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
" 1/ / QTY. ELECTRIC PERMIT FEE
.R �� (. PNONE
NAAMEACTDEs OUTLETS-SWITCHES-RECEP 10.00/1.00
INOV m TLIC. Z LIGHTING FIXTURES 10.00/1.00
/
CONTRACTORS
ADDRESS
APPLIANCES-RESIDENTIAL .00
ADDRESS 4
PHO 6- PANELS 10.00 DATE OF APPLICATION
ARCHITECT PA NELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC,No, SIGNS TRANS. 3.00
moo Ess E "G SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 f
w o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
o If/
//O�
/
¢ 0 U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
wQ m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H z Poitcssians Cade,and my license is in full fu c Je lett
, CL - License Class-z(,] Lie.Number�� 1-1
❑
0 m H w Date A / r Contracto9 �
a m E 7 ��} •' '� / f-I BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLARATION INFORMATION
o A Uw MISC.- REFER TO ORD; a w I hereby affirm that I am exempt from the Contractor's License VALUATION SIFT.
H .. oa Law for the following reason.(Sec.703L5,Businessand Professions PERMIT ISSUANCE 10.00
W Code:Any city orcounty which requires a permit to construct,alter,
2 ¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
n iL m LL requires the applicant for such permit to file a signet)statement that TOTAL PERMIT O
he is licensed pursuant to the provisions of the Contractor's License
H z i
Law(Chapter 9(commencingw•ith Section 7000)of Division3 ofthe M�
i a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
M I-o the basis for the el leged exemption.Any violation III Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant tea civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S50001:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their Sole cont pensnlion,will do the work,and the structure D not OCC.GROUP RES.UNITS
intended or offered lar 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 thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.ET.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees provided that such improve-
ments are not intended or offered for sale.Il',however.the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner - . -OVER 4 IEA.) 2.00- GAS EASYSTEM
builder will have the burden of proving that he did not build or im- BUILDING USE m
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Oer
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 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 property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with n contraclons)licenxd pursuant to
the Contractor's License Law. SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-.B&P.C.for this WATER HEATER W/VENT 6.00
rea50n
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Com ensalmn Insurance, r a cerlified ZONING ENG.SITE NO.
copy the rrn$(( 'c 3804 Lpab�4In)A
O I'oltcy Ndr$L[(OL�Com .I 1J
CX Cer flied copy is hereby furnished. FIRE$PRINK ENERGY TQ4
Z Z ❑ Certified copy is fled with the city inspection division. MISD.- REFER TO ORD.
O Applicant Y ❑ IN v ❑ N❑
cc: y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG,CONTE. LIC.NO. PLG. v❑ N❑ v❑ N E]CL O ('Phis section need riot be completed it the permit is for one TOTAL
D Z hundred dollars 1$100)or less,)
U 0 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 any nlannerso as to
O w become subject to the Workers'Compensation Laws of California. BUILDING
u D,nc' Applicant ALTER OR ADD TO MECH. 5.00
} W NOTICE*TO APPLICANT: If,after making this Certificate of Ex-
Z cuiplion,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(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 S
the performance of the work for which this permit is issued(See. MICROFILM
3097,Cie.CJ. HEATING UNIT(TO 100,000 B.T-U.) 8.00 01.
Lender's Addo HEATING UNIT(OVER 100,000 B.T.U.)9.50
me
Lender's Address ELECTRIC
I certify that I have read this application and state that IIIc above / VENTILATION FAN (SINGLE) 4.00
information is correct I agree to comply with all City and county BOILER- H.P.Or 100,000 B.T.U.) 6.00 PLUMBING •_
ordinances and state -
le laws relating to building construction, and
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) a ec to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. t
Cupertlo6ainst liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 dLi CONST.TAX
may an way accrue If said City in consequence of the �U
m In, this permit MECH.CONT. LIC.NO. MECH.
meq/ TOTALc 7�.1)v TOTAL
Slgnat plica ontractor Dale
INSPECTOR COPY