8417APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON
APPLICATION & PERMIT
UILDING- ELECTRICAL -PLUMBING - MECHANICAL
PERMIT NUMBER
I
BUILDING
ADORESs 4A
O N
NAME
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHONE
CONTRACTORS
UTLETS-SWITCHES -RECEP 10.00/1.00
uc. No.
LIGHTING FIXTURES 10.00/1.00
ADDRESS Its
APPLIANCES - RESIDENTIAL 4.00
PANELS 1 10.00
DATE OF APPLICATION
C
OR
PANELS 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
ENGINEER
LIC. No.
SIGNS TRANS. 3.00
ARCH. ENG.
'SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
f ZIP
J
D
AAOAMSS
DREss
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
/ '
S�J S
LICENSED CONTRACTORS DECLARATION
TEMP, POLE 30.00
I hereby affinm That I ant licensed under provisions Df Chapter')
(commencing with Section 7000) of Division 3 of the Business and
Professions Code d my license is in full force and - feet.
License Class Lic. Number
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
❑ ❑ ❑
Date Contractor
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
1 hereby affirm that I ng son exec. 7 from the Contractor's License
Code:Law Any citylorcountywhih re 7ireso emit cssonstrct,aloos
Code: Any city or county which rtqu permit taco issuance B aer,
DISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
'
ELEC. GONTR, LIC. N0. ELEC.
TOTAL
improve, demolish, or repair any structure, prior to its issuance. also
tune
requires the applicant for such permit t0 file a signed statement that
Ito is licensed'pIa want to the provisions of the Cmltr:nar's License
Law (Chapter 9f marred,with Section 7000)of uvision3ofthe
PERMIT TO
Mreff
Business and I fC 'ons Code) or that he is exempt therefrom and
QTY. PLUMBING PERMIT FEE
the basis for IIlc :dleg If exemption. Any violation of Section 7031.5STp
Eby any upplicaufora�cmrit subjects the applicant to a civil penalty
of not more than five h 6be red dollars (S500).1:
RIES,
ut ,,.
TYPE CONSTR.
ALTER-DRAIN&VENT-WATER (EA.) 5.00
'❑ I, as owner of the property, or my employees with wages as
their sole compensation; will Jo the work, and the structure is not
• / BACK F LOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
' DRAINS -FLOOR, ROOF, AREA, COND. 5.00
,intended or offered for sale (Sec. 7044. Business and Professions
Code: The Contractor's. License Law does not apply to an owner of
'
F IXTUR ES - PER TRAP 5.00
GAS - EA. SYSTEM -1INC. 4OUTLETS 6.00
so. FT. MOOR AREA
- TOTALACREAGE
propertywho builds or improves thereon, and who docs such work
himself or through his Own employees, Provided that such improve-
Tants'are not intended or offered for sale_ 11, however, the building
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
GAS - EA. SYSTEM -OVER 4 IEA.) 2.00
BUILDING USE
prove for purpose of sale,).INDUSTRIAL
❑ I, as owner of the property, am exclusively contracting with
RES IND CON PB Other
El ❑ El 0 0
. .
WASTE"INTER3000
licensed contractors to construct the project (Sea. 7044, Business
and Professions Code: The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. -6.00
.. ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
conducts for such projects with n contractor(s) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT No.
PARCEL NO.
❑ lam exempt under Sec... B.&P.C, for this
reason
"
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACGDATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
..u„WORKERS'COMPENSATION DECLARATION
-
I hereby alfbir that 1 haven certificate of consent to svH insure,
or a certificate of Workers' Compensation himranc ora certified
,,,,pa,
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800. Lab.C.I.
Policy No. Company
❑ Cort yis herebyfurn spivisi
❑ Ccr tried coy is fid w' ectian don.
Applicant
FIRESPRINK
YEJ Nw
ENERGY T 24
Y❑ NE]
DISC.- REFER TO ORD.
CER" IC TB OP IiA:iIRfIO PROM WORKERS'
PERMIT ISSUANCE 10.00
FLOODZONE
A.L.U.C.
.OMPENSAI'ION I SURANCE
(This sccti' need not be completed if the permit is for one
V N
V N�
PLG. CONTE. LIC. NO.
PLG.
TOTAL
hundre If rs f S 100) or less.)
I cerci y that in the performance of the work for which this per-
mit is issued, I shall not employ any, person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation laws of California.
Date Applicant
NOTICE '10 APPLICANT': Ili after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
PLAN CHECK
FEE
emption, you should become suhjcct to the Workers'Compensatiun
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (OVER 10MC.F.M.) 6.00
SEISMIC,FEE
CONSTRUCT ION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
- -
the performance of the work Iia which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00 /
Lender's Name
Lender's Address
HEATI NG UN IT 100,000 B.T.U.)9.50
ELECTRIC
I certify that 1 have read this application and store that the above
VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
hereby uu0wriee representatives of this city to enter upon the
above-mcmimwd property Or inspection purposes.
BOILER -COMP (over 100,000 BTU) SEE FEE SCH.
MECHANICAL
(/(
e) agree to ve, indemnify and keep harmless the City of
Cuperh ag:' t costs and expenses which
may in erne ainst said t}' in consequence of the
DISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
grand u. perm.
MECH. CONT. LIC. NO.
MECH.
TOT
TOTAL
Sign ankrplr nI/qoh1,.cVr
INSPECTOR COPY //