09713 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING 167 APPLICATION & PERMIT ��7�
AGD/D/R�ESS -1 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S / PLAN CHECK VALIDATION
NAME y'1 QTY. ELECTRIC PERMIT FEE
PHONE
• CONTRACTOR OUTLETS-SWITCHES-RECEP 10.00/1.00 11-Af3ti
7A E
1 F(� J(' C. LIC NJ/2 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
A7oREsa
S•TPHON - PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.N0.
OR
PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH,OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP EMP. METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
E55
SERVICE CHANGE 20.00
,00 LICESED CON"TRACTORS DECLARATION TEMP.POLE x 30.00
¢ u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H a N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r y z I'rofssfon,C r, mY license is in full f�isaijdt0ept.r, ❑ ❑ ❑ rI
z o in - LicensepC_lass Lie.Number LL 11 IIJJ LLT I"Xt"I
O H D IJa0.• 7`/l, r.x" ConlracturQt�l(, ���I
ays � b-7 1``•.``•�r���I BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION
INFORMATION
aoA MISC.- REFER TO ORD -
e, ;U. b I hereby affirm that I am exempt from the Contractor's License VALUATION S/PT.
FU04 Law forthe following Reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which rcquiresu permit to construct aheq
Ra, Q O improve,demolish,or repair any sti'venne,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O u requires the applicant for such per...it to file a signets statement that TOTAL PERMIT TO
u w m he is licensed pursuant to the provisions of thac
e Contractor's License
Hzi Law Wimple,9(commenefng with Section 7000)of Division 3 o fill,
4 [fastness and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE i'1I� _
¢ H p lhe,basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
nam by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($5001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA.COND. 5.00
Code:The Contractor's License Law dos not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 So.FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees,provided that such improvo
himself
sfo through
ot oroffered for employees, le.If,provided
Im.tvedthat suhebu ldingrove. GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA.) 200
builder will have the burden of proving that he did not build or fm - . - . .
. BUILDING USE
jirove for purpose of sale.). 2 INDUSTRIAL WASTE INTER30.00 RES IND CON pe Other
❑ I,us owner of the property,ant exelussely con tr.,tfn .g wfth ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044, BL,incs-s LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors I.i,eHw 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 contractor(,)licensed pursuant to -
theContractor'sLicenseLaw. SEWER-SANITARY-STORM EA,200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 ran exempt under Sec. .13AP.C.for this WATER HEATER W/VENT 6.00
tease Is
Owner Date WATER SYSTEM- 5.00
ACC.DATE ACC,FILE NO.
W'ORKFRS'COSf`FNSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a Certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITENO.
copy there Sec 3600,Lub.C)��.I- �
I'n1luicty No I umpany!`�[J2M1r 1 A.)9
O I' C,filled copy is hereby lumishcd. FIRE SPRINK ENERGY T 24
Z Z ❑ Cer Icd copy is tiled with Ill, sly inspection division.
O Applican �,{} MISC.- REFER TO ORD. v ❑ N❑ v ❑ N❑
� y CERTIFICATE OP 1 XE%1PIION 17RONI WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.UC.
L COSIPENSATION INSLJRANC17 PLG.CONTR. LIC.NO. PLG.
CL Z ('Phis section need not be completed if the permit is for one TOTAL Y[:J NE] Y❑ N❑
hundred dollars IS 100)or less.)
U O 1 certify that In the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Laws of California. '
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Fs-
f- 2 e..ptioi.you should become subject to the Workers'Compensation APPLIANCE 1 5.00 PLAN CHECK
provisions of the Labor Code, you must lixthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10MC.F.W 4.00
CONSTRUCT ION LENDING 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
t the performance of the work I'or which this permit is issued(Sec. v 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.19.50 I4
Lender's Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 (�V
i • information is correct I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 -1
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 RTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(W,) agree.to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertimi rgainst liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 (f d CONST.TAX
for, 'n aI wryy accm against said City in consequence of 0i,
Ban n• "t his pens.I MECH.CONT. LIC.NO. MECH.
TOTAL a TOTAL
Signa r "A 1 (Contractor /Dot
INSPECTOR COPY