7053 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
3011111NG APPLICATION & PERMIT 7053
AWRE55 r
Y BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME H['� 11 �^ OTY. ELECTRIC PERMIT FEE
4_ A) AJPHONE
CONTRACTORS OUTLETS
5.00/1.00
NAME
I.C.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR OR's PPLIANCES-RESIDENTIAL 4.00
CONTRAS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS - 6.00 PLAN CNECK FEE P.C.NO.
OR
ENGINEER
L1c,No, SIGNS TRANS. 3.00
AARC
DDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
7
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT S MOTORS SEE FEE SCR. J
ADDRESS ,
SERVICE CHANGE 10.tl0 4
S Dietz
¢O o LICENSED CONTRACTORS DECLARATION a
III a u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
as a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F H z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ O
2 0 - License Claes U,Number
0 z Date Contractor
a y s BUILDING PERMIT
or ecw OWNER-BUILDER DECLARA PION INFORMATION
wn .- I hereby affirm that 1 an exempt from Om Contractors License MISC.- REFER TO ORD
..'oa Law Ii,r the Hollowing Haran.(See.703 LS.Business and Professions PERMIT ISSUANCE VALUATION S/FT.
� - Code:Any city orcounly whichreQuiresapennit to CnnstrnQ,allet, 6.UO
Q 2 improve,demolish,or repair airy structure,prior to its issuance,also ELEC-CONTR. LIC.NO. ELEC. /
d m u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
X he is licensed pursuant to lire provisions of the Contractor's Li ruse .r C
HiQ Law(Chapter 9(commencing with Section 7000)of Division 3 oflhn
E 4 0 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
H p the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
,c _ by any applicant for a permit subjects the applicant on civil penalty ALTER-DRAIN&VENT-WATER (EA.) 400
of not INC.than five hundred AollarS(55001.):
❑ I,as owner of lire property,or my employers with wages as BACK FLOW PROTECT.DEVICE 2.00 - 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. 4.00
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 4.00 Sa FCFLOORAREA TOTALACREAGE
himself or through his own employees.provided that such improve. i
mens{are not intended proffered for sale.If.however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement Is sold within one year of completion,the owner. GAS EASYSTEM-OVER 4 (EA) 100 BUILDING USE
builder will have the burden of proving thal lied - . . .
id not build or im- RES IND CON PB orae(
pr vc for purpose ofole.). INDUSTRIAL WASTE INTER. 20.00
1,as owner of the property,am exclusively contracting with 13El ❑ El El
licensed contractors In construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. .5.00 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(EA.) 1.00
contracts for such projects with a contraclons)licensed pursuant to
Ora Contractor's License aHv. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am us n t u cr 'tic. .B.&P.C.for Deis WATER HEATER W/VENT 4.00
rens,
Owner Date - R WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WOR ERS'COMPENSATION UECLARA'rION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers Compensation Insurance,or a certified
copy thereof(See 3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is Filed will, the city inspection division. MISC.- REFER TO ORD.
Q Applicant Y❑ N❑ Y❑ No
� N CERI'IFICAI'E 01:EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.c.
LU > COMPI-NSA'1TON INSURANCE PLG.CONTE. LIC.NO. PLG. V❑ NE] Y❑ NE]
(This scclilo, need nM be completed if the permit is for one TOTAL
Z hundred dollars 1$100)or less.)
U O 1 I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit
is issued,1 shall not employ any person io any manner so as to
"
U become subject to the Workers Com ensalion Lawz of California. /
O w ) p - BUILDING �(0 +
St. Date Applicant ALTER OR ADD TO MECH. 4.00 �+
} rn NOTICEtion,TO should become
: IL after making this Certificate of ISs-
F ? emotion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions io n
the Labor Code, You must forthwith comply with
such FEE
U such nos
isions or this pcnit shall be de ,000G
cmaJ revoked. AIR HANDLING UNIT(TO 10F.M.1 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000C.F.M.) 5.00 SEISMIC FEE 77
1 hereby affRGr that there is A construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which.this permit is issued(Sec. HEATING UNIT ITC 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.).
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.17.50
Lenders Address ELECTRIC
1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
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.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000BTU)SEEFEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indenmify and keep harmless the City of MISC.- REFER TO ORD. -
Cupertinorgai t habjli'es,judgm W cuts, costs mexpenses which CONST.TAX
may in y way a Fore against said City in consequence of the PERMIT ISSUANCE 3.00
granting 1 jl' r V. MECH.CONT. LIC.NO. MECH[. O.]
TOTAL TOTAL =
Signature i3 p ant Contractor Uafe
INSPECTOR COPY