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APPLICANT TO FILL-IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
r'PERMIT
BUILDING PROJECT IDENTIFPY
ICATION APPLICATION & PERMIT
BUILDING
ADD Ess G BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
a
NU BE
C
J
OWNER'S
N /, QTY. ELECTRIC PERMIT FEE.
PLAN CHECK VALIDATION
�j.. P
-
-
DATE OF APPLICATION
CONTRACTOR'S
AME
LIL ^
OUTLETS --SWITCHES - RECEP 5.00/1.00
LIGHTING -FIXTURES 5.00/1.00O
CO NTRACroR' _ /)
RE$S
APPLIANCES- RESIDENTIAL 4:00
PANELS 5.00,-
'ToELT
0
EN EER
LIC. NO.
SIGNS 6.00
PLAN CHECK FEE
P.C. NO:
-
SIGNS TRANS. 3.00
AFK.OR G.PERMIT-VALIDATION
ADDRESS
zip
SPECIAL CIRCUIT 5.00
'
EMP. METER OR POLE INS. 15.00
APPLICANT' -
ADORESs
MOTORS E FEE SCH.
S41*11
ERVI A 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions C license is in full f gd effffl
License Class Lic. Nu e Y
ISSUANCE DATE
- ,-
BLDG.
ELECT.
PLG.
MECH.
Date Con r
I BUILDING PERMIT
1 = INFORMATION
�/
4/714KEil-BUILDER DE ARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 703 1.5. Business and Professions
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
•
MISC. - REFER TO ORD
.VALUATION '•'
$/FT.
'
PERMIT ISSUANCE .6,00
•�
E1EC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT.TO
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 -(commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that lie is exempt therefrom and
STORIES
TYPE CONSTR:
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant toacivil penalty
of not more than five hundred dollars (5500).):
ALTER -DRAIN &VENT -WATER (EA:) 4.00
❑ I, as owner of the property, or my employees with wagesas
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC_GROUPRES.
UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
intended or offered for sale -(Sec. 7044. Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself.or through his own employees,. provided that such improve-
ments are not intended or offered for sale. If; however, the building
FIXTURES - PER TRAP 4.00
so. FT. FLOOR AREA
TOTAL ACREAGE
es
GAS - EA. SYSTEM - 1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will'have the burden of proving that h e did not build or im-
prove for purpose ofsale.).
❑ 1, as owner of the property, am exclusively contracting with
.
GAS -'EASYSTEM -OVER 4 (EA:) 1.00
-
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ ❑ . ❑
INDUSTRIALWASTE INTER. 20.00
licensed contractors to construct the project (Sec. 7044, Business
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 - 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
'TRACT
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM- EA. 200ft/8:00
NO..
PARCEL NO.
❑ 1 ani exempt under Sec. B.&P.C. for this
r WATER HEATER W/VENT 4.00
reason
Date Owner
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO
4,V
WORKERS'COMPENSATION DECLARATION
WATER TREATING EQUIP, 4.00
hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Comp s an certified
ZONING
ENG. SITE NO.
Lab.y
npany
6e ois reby furni d.
' fit witl is 'on.
riha
_
FIRE SPRINK
- Y ❑ No
ENERGY T-24
Y ❑ NQ
MISC. - REFER TOORD.
CERTI KATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
'O�
FLOOD ZONE
A. L. U.C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for 'one
Y ❑ N❑
Y ❑ N❑
PLG. CONTR. LIC. NO.
PLG.
TOTAL
hundred dollars IS 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, 1 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 ApplicantALTER
OR ADD TO MECH. 4.00 -
NOTICE TO APPLICANT' If, after making this Certificate of Ex-
APPLIANCE 4.00
PLAN CHECK
FEE
emption, you should become subject.to the Workers' Compensation
provisions of the Labor•Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked..
AIR HANDLING UNIT (TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY
AIR HANDLING UNIT (OVER 10=C.F.M.) 5.00
SEISMIC FEE
/
I hereby affirm that there is a constructio lending agency for
the performance of the work fO whic his rmit is issued (Sec.
3097,Civ.C.).
EXHAUST HOOD.(WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
T
HEATING UNIT (OVER 100,600 i
000 B U
,...)7.50
ELECTRIC
1 certify that I have read this application and state that the above
information is correct. 1 agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) ';. 3.00
oe .
BOILER - COMP (3 H.P. or 100,000B.T,U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify an eep harmless the City of
Cupe o ai liabilities Brae costs and expenses which
I In accrue a t sat ity in consequence of the
MISC. - REFER TO ORD.
CONST. TAX
-,
PERMIT ISSUANCE 3.00 -
gr
Signature . A h ant/Contractor Dae
MECH. CONT.•LIC. NO.
MECH.
TOTAL "�O- T
TOTAL
�/
7 -ZA
�! .
OFFICE COPY
C I T Y I
0 F C U P E R T I N 0
Building Division
_�D
PROJECT A0 r G
ADDRESS- J7
OWNER PHONE
ADDRESS
REP. PHONE
ARCHITECT PHONE
ADDRESS
REP.PHONE
CONTRACTOR LIF, - 6- , ;.)o c) 4S PHONE 70 76
ADDRESS
REP. PHONE
PLAIT CHECK HOURS
DATREc.,DATE RET.
CONTROL #
PERMIT #
SAN. #
BLDG. TYPE
OCC. GROUP
VAL. $ et -0
StZRUCT.PLAN CK
DG. P ?S/(jCK
PERMIT FEE
CAP FEE
CONST. TAX
ENERGY FEE
TOTAL FEES
BLDG. DEPT.
ENG. DEPT.
PLAN. DEPT.
STRUCT. ENG.
CENTRAL FIRE DIST.
-HEALTH DEPT.
-SAN. DIST.
-ENERGY
-HANDICAPPED
C.I.CS' OF CUPP,RTINO IIISPI.,CTIOV RECORD (Office Copy)
yl
2157 _ _ 20368 Clay St. _
Pf.;P.P1IT 1`10. SANITARY DIST. NO. LOT NO. Al)1)1:1•',SS
FINAL, INSPECTIONS
Date Insp.
F1ec tric
Plumbing
Mechanical
Solar
Pool
Gradin
Planning
Fire Dept.
Health Dept.
Building
Other
BUILDING
Date ' Insp.
Foundation
Pre-Gunite
Slab -Membrane
Bond Beam
Underfloor Girders
Floor Steel
Tiedowns
Diaphrams
Seismic Bracing
halls -Panels
Frame
Lath
Ilallboards Int/Ext.
Firewalls
Other
Not Approved
01•INER JOB SITE PHONE NO.
ELECTRICAL
Date
Power Pote I
I. Ding
PROJECT
PERMIT ISSUED
Date
Buil ding,
7-7-82
1:1.ectr ical
7-7-82
Plumhing
7-7-82
itcclian ical
7-7-82
Temp. C:as/1lcct.
_
Solar
Fire Sprinkler
Sign
_
Hisc.
FINAL, INSPECTIONS
Date Insp.
F1ec tric
Plumbing
Mechanical
Solar
Pool
Gradin
Planning
Fire Dept.
Health Dept.
Building
Other
BUILDING
Date ' Insp.
Foundation
Pre-Gunite
Slab -Membrane
Bond Beam
Underfloor Girders
Floor Steel
Tiedowns
Diaphrams
Seismic Bracing
halls -Panels
Frame
Lath
Ilallboards Int/Ext.
Firewalls
Other
Not Approved
01•INER JOB SITE PHONE NO.
ELECTRICAL
Date
Power Pote I
Insp.
Underground
/
Rough Wiring
Ilal7.s
Ceiling
_
Fixtures Int/Ext
Motors
_
Grounding
Temp. Power
Other
_
Not Approved
PLUMBING
Date
Backflow
Insp.
Underground
_
Underfloor
Partial P.ou ;ll
Rough Complete
Solar Rough
[Later & Insulation
_
Main Drain
R/of/S Drain
Gas y� O1—
Other
Not Approved
MECHANICAL
Date
Underfloor S.M.
Insp.
Ducts & Insulation
_
Fire Dampers
_
Fireplace
Grease Duct & flood
One flour Shaft
Condensate Drain
Equipment Anchorage
Flues & Comb. Air
Other
Not Approved
BUILDING
ELECTRICAL
PLUMBING
MECHANICAL
MISCELLANEOUS
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