09721 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT �� 1 ��
PDDR 55
/ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
WNER' PLAN CHECK VALIDATION
AME QTY. ELECTRIC PERMIT FEE
� A S Oa�JT/V
PHONE
CQ THACTOR'S
�Y (NAME ,/ [OUTLETS-SWITCHES-RECEP 10.00/1.00
af
( hao/ uc.Noy LIGHTING FIXTURES 10.00/1.00
ADDRESS oRs PPLIANCES-RESIDENTIAL 4.00
CONTRACTOR
nl 't PHON PANELS 10.00DATE OF APPLICATION
'ARCHITECT PANELS (OVER 200 AMP) 20.09 PLAN CHECK
OR FEE P,C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARC" OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00 1
APPLI ANTS MOTORS SEE FEE SCH. L/,I�Ld'd`/h'J
ADDRESS
SERVICE CHANGE 20.00
000 LICENSED CON'I'RACfORS DECLARATION TEMP.POLE 30.00 0
a E,v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H z "' (commencing with Section 7000)of Division 3 of the Business and
¢ H BLDG. ELECT, PLG. MECH.
F N z Professions Co/'�.`•.�a�dd m�Y��icense is in full f re and of ec. ❑ ❑ ❑
z O m - Licensc ClassL-��J-Lic.Number
0 z D Data Contractor
f a m s \Ir-i, BUILDING PERMIT
¢ E W Q OWNER.BUILDER DECLARATION
E
3n I- I hereby affirm that I am exempt from the C'ontractor's License MISC.- REFER TO ORD
e_ U- J Law bar the following reason. 7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� - 0 Code:Any city orcounty which requiresa permit to construct,alter,
Qae Q O improve,demolish,Or repair any structure,prior to its Issuance,also ELEG CONTR. LIC.NO ELEC.
u w m LL r rey uirrs the applicant for such permit to file a signed statement that TOTAL PERNtlT TO
he is licensed pursuant to the provisions of the Contractor's License
F z
Law(Chapter 9(contmencing with Section 7000)of Division 3 of the
¢ Business and Professions Code)or that he is exempt therefrom and QTY- PLUMBING PERMIT FEE
It r 0 the basis for the alleged exemption.Any violation of Seelion 7031.5 STORIES TYPE CONSTR.
to
by any applicant for a permit subjects the applicant In a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not reme than live hundred dollars(S500).):
O I,as owner of the property,or myemplosees with wages as BACK F LOW PROTECT. DEV ICE 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,AR EA,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 F IXTUR ES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
•
himselforthrough his own employees.provided that such improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
meats are not intended or offered for sale IC mplevcc the building
or lder will have
is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
RES IND CON PB Omer
pros 1,as ownerose
of Lire property,
INDUSTRIAL WASTE INTER. 30.00
❑ d as owner of too proton Y.ata rojectiv Se contracting with ❑
licensed contractors m construct the project(Sec. does or apps LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
and Professions Code:The Cont unor's Li Prov s th docs not apply
In tr owner of property who builds tr improvesensed uand who LAWN SPRINKLE RS-OVER 5 (EA.) 1.00
contracts for such censeprojects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL No.
O um exempt under Sec. ,tl.&P.C.for This WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self insure, ZONING
Or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy them ce 800,lab,C/I J.'Y,r._ / - D
I'ol�'�cyy�Compunl LP L*P,)
O gL,Certified copy is hereby furnished. FIRE SPR INK EN ERGY T-24
Z Z Certi ied copy is fdod with the it inspection division.
O nPncho - ,_ /, .'a`1_ _ _ MISC.- REFER TO ORD. Y0 N� Y0 N�
N CF-RTIFICA'fli OF_lFXEMPTION PROO-M WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LLQ COMPF,NSA'1'ION INSURANCE PLG.CONTR, LIC.NO. PLG. v� N� vE NEI
IL Z (This section need not be completed if the permit is for one - TOTAL
hundred dollars IS 100)or less.)
L) O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person io any manner so as to
O Qbecome subject to the Workeri Compensation Laws of C'ulifornia. a
C_ Datc npplle°nt ALTER OR ADD TO MECH. 5.00 BUILDING
} EO NOTICE '1'0 APPLICAN'1: IL after making this Certificate of Ex-
F ? emption,you should become subject to the Workers'Cumpensution APPLIANCE 5.00 PLAN CHECK
provisions of tiro 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
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 m9
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I have read this application and state Ihat the above VENTILATION'FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construclion, and BOILER-COMM H.P.or 100,000 B.T.U.) 6.00
hereby antione a representatives forfives ec this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCM. MECHANICAL
above hereby mentioned property for inspection purposes.
(We) agre�e to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
CupertiZanway
' st liabilities,judgments, costs and expenses which CONST.,TAX '
n y accrue inst said City in consequence of the PERMIT ISSUANCE ' 10.00mI ermiL MECH.CONT. LIC.NO. MECH.
-�/ - TOTAL t)3 d TOTAL
Signa tu p II ontractor Date
INSPECTOR COPY ,
- I