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5042C I T Y O F u U P E R T T N 0 aiid; .).v- PROJECT .).ai PROJECT C c= L/ L,Q6-- CONTROL # .� � ADDRESS 'COS-/ P SA a j'�/ A A Vg- PERMIT # OWNER PHONE A.P.N. # ADDRESS SAN. # REP. PHONE BLDG. TYPE ARCHITECT PHONE OCC. GROUP ADDRESS /il %oZy yi T�- REP. PHONE CONT1-,ACTOR PHONE VAL. $ ' 02 O "V ADDRESS Ad S7°UCT . f �-� REP. PHONE BLDG . PLAN . CK�� . PLAN CHECK HOURS t -o PERMIT FEE�– CAP FEE ` CONST. TAX 0 (�d O NEECf �E- PUBLICWORKS MICRO FILM FEE TOTAL SEES lst. Submittal 2nd. Submittal 3rd. Submittal DATE REC. DATE:REC. DATE REC. DATE REC. * DATE REC. DACE REC. BLDG. DEPT. Y, ENG. DEPT.fit PLAN. DEPT. T rJ.>�IL. ENG. ((f J ENERGY HEALTH DEPT. -- - SAN. DIST. i y y .._ CENTRAL FII I A. C4 G -6 f'�) - 0 HANDICAPPED i t —t- �t A. - APPROVED C /7ldler N.A. - NOT APPROVED _,APPLICANT TU FILL IN INFORMATION WITHIN RED LINES - USE BALL PQaA1JTP-EN ONLY BUILDING PROJECT IDENTIFICATION MADDDRESSRESS ADAPPLICATION & PERMIT � 1001st GHSi4be_IJA ktri BUILDING - ELECTRICAL- PLUMBING - MECHANIC NAME .,w�. CONTRACTOR'S LIGHTING FIXTURES PHONE JJQ �-QI - � APPLIANCES - RESIDENTIAL 4.00 PANELS 5.00 SIGNS _09F -CA A '^ IJ I C [y! LIC. NO. MOTORS SEE FEE SCH. CONTRACTOR'S 10.00 PERMIT ISSUANCE 3.00 r ADDRESS - TOTAL / A). i 0 �l �t tip PHOfNE dU V _.p `1! 5s, AAKCC{/H,I I tCI OR ENGINEER LIC. NO. ARCH. OR ENG. ADDRESS APPLICAt ADDRESS DTY.I ___-�-.. _...._._.�_..............._.�._ i _,�-..__. ELECTRIC PERMIT FEE PLAN CHECK 0 ¢ Z ,02 LICENSED CONTRACTORS DECLARATION tc Uw w I hereby affirm that I am licensed under provisions of Chapter 9 w ¢ a (commencing with Section 7000) of Division 3 of the Business and N ,N Professions Codyyqq= d y license is in full ford t�� ZZ 0 w a License C s-_/„� - Lic. Number 2 w L J Date- Contractor ^ ' E 2 w OWNER -BUILDER DECLARATI N w: LL N I hereby affirm that I am exempt from the Contractor's License r LL o ¢ Law for the following reason. (Sec. 7031.5, Business and Professions w J Code: Any city or county which requires a permit to construct, alter, ¢¢ improve, demolish, or repair any structure, prior to its issuance, also TL -EC a ao u requires the applicant for such permit to file a signed statement that X m ti he is licensed pursuant to the provisions of the Contractor's License F Z a Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and QTY Or � 0 the basis for the alleged exemption. Any violation of Section 7031.5 a 3 .- by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): 0 I, as owner of the property, or my employees with wage's, a5 their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: 'file Contractor's License Law does not apply to an owner of _. property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- ments are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not build or im- prove for purpose of sale.). ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to constrhit (lie projeel (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of properly who builds or improves [hereon, and who contracts for such projects with a cuntractor(s) licensed pursuant to the Contractor's License Law. ❑ I am exempt under Su. , B.&P.C. I'or This reason Owner Date WORK F.RS'COMPENSATION DECLARATION 1 hereby affirm [hat I have a certificate of consent to self' -insure, or a certificate of Workers' Compensation Insurance, or a certified copythere 'f$..r3 00, Lab.C.) _ 7- Policy mpany- %__.,L/►%� 0 0 Certilie opy' hereby ' t¢h Z z' ❑ Certif is file I y 't Pe`tion division. p p' Applican c w CERTIFICATE OF EXEMPTION FROM WORKERS' LV COMPENSATION INSURANCE PLG. VC' ES (This section need not br•cornpleted'if the permir is for one ZO hundred dollars ($100) or less.) , 1 certify that in the performance of the work for which this per - LL 1-- mil is issued, 1 shall not employ any person in any manner so as to QTY w0 become subject to the Workers' Compensation Laws of California. CL Date Applicant } rq NOTICE TO APPLICANT: If, after making this Certificate of Ex- I- Z emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with V such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ.C.). Lender's Name Lender's Address I certify that 1 have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property forinspectio, purposes. (We) a ree to save, indemn"y a keep harmless the City of Cupertil 'gains[ liabilities, jt gmc Is, costs and expenses which may wa accrue a st s Ci[y m onssequence of [the ` gra � [. 11--.2/' A MECH. OUTLETS -SWITCHES- RECEP 5.00/1.00 LIGHTING FIXTURES 5.00/1.00 APPLIANCES - RESIDENTIAL 4.00 PANELS 5.00 SIGNS 6.00 SIGNS TRANS. SPECIAL CIRCUIT TEMP. METER OR POLE INS. 3.00 5.00 15.00 MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 MISC. - V V R FE TO ORD PERMIT ISSUANCE 6.00 :ONTR. LIC. NO. ELEC. TOTAL r rr PLUMBING PERMIT ALTER -DRAIN & VENT -WATER (EA.) 4.00 BACK FLOW PROTECT. DEVICE 2.00 DRAINS -FLOOR, ROOF, AREA, COND. 4.00 FIXTURES - PER TRAP 4.00 GAS - EA. SYSTEM -1INC. 4 OUTLETS 4.00 GAS - EA. SYSTEM - OVER 4 (EA.) 1.00 INDUSTRIAL WASTE INTER. 20.00 LAWN SPRINKLERS - 1 INC 5 V.B. 5.00 LAWN SPRINKLERS -OVER 5 (EA.) 1.00 SEWER -SANITARY -STORM EA.200ft/8.00 WATER HEATER W/VENT 4.00 WATER SYSTEM 4.00 WATER TREATING EQUIP. 4.00 OF BER 6606 TION PtHM1 r VALIDATION ISSUANCE DATE BLDG. ELECT. PLG. MECH. ❑ �. ❑ ❑ BUILDING PERMIT ;INFORMATION VALUATION$/FT. FEE SO. FT. FLOOR AREAL TOTAL RES IND CON PB Other _❑ ❑ ❑ ❑ ❑ ASSESSORS PARCEL NO. L ENG. SITE NO. FIRE SPRINK ENERGY T-24 MISC. - REFER TO ORD. Y ❑ N❑ Y ❑ No PERMIT ISSUANCE 6.00 FLOOD ZONE A. L. U.C. INTR. LIC. NO, PLG. TOTAL Y ❑ N ❑ Y ❑ N ❑ MECHANICAL PERMIT FEE FEE SUMMARY ALTER OR ADD TO MECH. 4.00 BUILDING APPLIANCE 4.00 PLAN CHECK FEE AIR HANDLING UNIT (TO IQOWC.F.M.) 3.00 AIR HANDLING UNIT (OVER IO,000C.F.M.) 5.00 SEISMIC FEE MICROFILM ELECTRIC PLUMBING EXHAUST HOOD (WITH DUCT) 2.00 HEATING UNIT (TO 100,000 B.T.U.) 4.00 HEATING UNIT (OVER 100,000B.T.U.)7.50 VENTILATION FAN (SINGLE) 3.00 BOILER-COMP(3H.Ror100,0006.T.U.) 4.00 BOILER -COMP lover 100,000 BTU) SEE FEE SCH. MECHANICAL CONST. TAX MISC. - REFER TO ORD. PERMIT ISSUANCE 3.00 CONT. LIC- NO. MECH. TOTAL - TOTAL o¢z moo w Q U U f,Zw V) Q N I-Nz Z O v, O z D Q Y 2 J E p W U M O a X 3 W I.- 0 O Q u, w Ir Oil a X o LL W co N Z =E F- 0 0 zz O UJ � z U o LL U 0 w in Z U APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 13UI LDI NG PROJECT I DENTI FICATION APPLICATION & PERMIT BUILDING ADDRESS Q�' �'q� �h- V BUILDING - ELECTRICAL- PLUMBING - MECHANICAL OWNER'S NAME 1 hereby affirm that there is a construction lending agency for he performance of the work for which this permit is issued (Sec. W97,Civ.C-f Name -I C-U-1Ol ��jNS %P HONE 0TX• ELECTRIC PERMIT FEE CONTRACTOR'S VENTILATION FAN (SINGLE) 3.00 BOILER- COMP (3 H.P. or 100,000 B.T.U.) 4.00 NAME OUTLETS - SWITCHES - RECEP 5.00/1.00 ��rCl��'�C1.g.1 R J(/h�jlrvli o. LIGHTING FIXTURES 5.00/1.00 CONTRACTOR'S ADORE ss PPLIANCES- RESIDENTIAL 4.00 22932 kt}txaxi`- P-ONE44 f- -I PANELS ARCHITECT OR `s �, tat SIGNS 5.00 6.00 ENGINEER SIGNS TRANS. 3.00 LIC. NO. ARCH. ORENG. ADDRESS SPECIAL CIRCUIT 5.00 EMP. METER OR POLE INS. 15.00 ZIP APPLICANT'S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 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 Code, and my license is in full force and effect License Class__ Lic.Number_ Date_ f % Contractor OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the following reason. (Sec- 7031.5, Business and Professions Code: Any city or county which requiresa permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also ELEC requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and QTY the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions 1 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 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- prove for purpose of sale.). ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The C'ontractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. ❑ lam exempt under Sec. , B.&P.C. for this reason Owner Date WORKERS' COMPENSATION DECLARATION I hereby affirm that 1 have a certificate of consent to self -insure, ora ,erlific:de of Workers' Compensation Insurance, or a certified copy I (Sec. 3800,La Policy No R (Company --Er-Certified copy is hereby furnished. ❑ , Certified copy is filed with the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE L (This section need not be completed if the permit is for one hundred dollars ($100) or less.) 1 certify that in the performance of the work for which this per- QTY mit is issued, I shall not employ any person in any manner so as to become subject to the Worke75' Compensation' Law's of California. Date Applicant MISC. - REFER TO ORD PERMIT ISSUANCE 6.00 'ONTR. LIC. NO. ELEC. TOTAL PLUMBING PERMIT ALTER -DRAIN & VENT -WATER (EA.) 4.00 BACK FLOW PROTECT. DEVICE 2.00 DRAINS -FLOOR, ROOF, AREA, COND. 4.00 FIXTURES - PER TRAP 4.00 GAS-EA.SYSTEM-11NC.40UTLETS 4.00 GAS - EA. SYSTEM - OVER 4 (EA.) 1.00 INDUSTRIAL WASTE INTER. 20.00 LAWN SPRINKLERS - 1' INC 5-V.B. 5.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 SEWER-SANITAR't-STORK EA.200ff/8.00 WATER HEATER W/VENT 4.00 WATER SYSTEM: i L j'j1't ul tV 4.00 WATER TREATING EQUIP. 4.00 FEE MISC. - REFER TO ORD. PERMIT ISSUANCE 6.00 (a - LIC. PLG. S. TOTAL 09 MECHANICAL PERMIT I FEE NOTICE TO APPLICANT: If, after making this Certificate of Ex- ALTER OR ADD TO MECH. 4.00 antplion, you should become subject to the Workers' Compensation Provisions of the Labor Code, you must forthwith comply with cuch provisions or this permit shall be deemed revoked. APPLIANCE 4.00 AIR HANDLING UNIT (TO 10,000C.F.M.) 3.00 AIR HANDLING UNIT (OVER 10,O1)OC.F.M.) 5.00 CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for he performance of the work for which this permit is issued (Sec. W97,Civ.C-f Name EXHAUST HOOD (WITH DUCT) 2.00 HEATING UNIT (TO 100,000 B.T.U.) 4.00 -ender's .tinder's Address H EATI NG UN IT (OV ER 100,000 B.T.U.)7.50 1 certify that I have read this application and state that the above nfonnation is correct. 1 agree to comply with all city and county Irdinances and state laws relating to building construction, and iereby authorize representatives of this city to enter upon the bove-mentioned property for inspection purposes. VENTILATION FAN (SINGLE) 3.00 BOILER- COMP (3 H.P. or 100,000 B.T.U.) 4.00 BOI LER-COMP (Over 100,000 BTU) SEE FEE SCH. (We) agree to save, indemnify and keep harmless the City of upertino ag;tins[ liabilities, judgments, costs and expenses which ay it In way Ic I e against said City in consequence of the MISC. - REFER TO ORD. PERMIT ISSUANCE 3.00 MECH. CONT. LIC. NO. MECH. azure (Applicant/Contractor Uate -C-11 -- IT PLAN PLAN VALIDA PERMIT VALIDATION t ISSUANCE DATE BLDG. ELECT. I PLG. MECI El BUILDING PERMIT ACREAGE RES IND CON PR Othar ❑ _❑ - ❑ ❑ ❑ ACC- DATE I ACC. FI ENG. SITE NO. FIRE SPRINK Y ❑ N❑ ENERGY T-24 Y ❑ N❑ FLOOD ZONE Y❑ N❑ A.L.U.C. Y[3 N❑ FEE SUMMARY BUILDING PLAN CHECK FEE SEISMIC FEE MICROFILM ELECTRIC PLUMBING MECHANICAL CONST. TAX TOTAL n' Ll'" 1 , v " 11\1 Iivrul-ilV"k I IUN VVI I tIIIV RED LINES -USE BALL POINT 13EN ONLY BUI LDI NG PROJECT I DENTI FICATION ESS NAME Bill Kinst RollaSnd Share PRONE CONTRACTOR' ��'�•� NAME Asmac Coro LIC No 24 rONTRACADDRESS TORS Newark, CA. 94560 7855 Enterprise Dr:HONE 79 OR ENGINEER ARCH. OR Et ADDRESS APPLICANT'S ADDRESS LIC. NO. ZIP APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL o¢i '02 LICENSED CONTRACTORS DECLARATION 4 cr z w 1 hereby affirm that I am licensed under provisions of Chapter 9 N Q a (commencing with Section 7000) of Division 3 of the Business and r N z Professions C�1 e�rrdCn� cense is in full fore u� , zo z y o License Class J Lic. Number `f 1�2 ,2 > J Date Contractor OWNER -BUILDER DECLARATION a O n w 3 a 1 hereby affirm that 1 am exempt from the Contractor's License F LL o Q Law for the following reason. (Sec. 703 1.5, Businessand Professions w Code: Any city or county which requires a permit to construct, alter, w ¢ Qo o improve, demolish, or repair any structure, prior to Its Issuance, also ELEC a a o a requires the applicant for such permit to file a signed statement that W m v, he is licensed pursuant to the provisions of the Contractor's License F Z > Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Q Business and Professions Code) or that he is exempt therefrom and QTY w 1- the basis for the alleged exemption. Any violation of Section 7031.5 a 3 T by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not 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 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- prove for purpose of sale.). ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Seca 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 contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. ❑ 1 am exempt under Sec. , B.&P.C. for this reason Date Owner WORK ERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' CompetRtLitS Irl Tan�or certified copy thereof (Sea 3800, Lab.C.). Policy No. Company yri-I I_nSux,-In O Certified copy is hereby 1' 13urms ted. z z rtified copy is filed with the city inspection division. )- o pto 1 _ N CERTIFICATE OF EXEMPTION FROM WORKERS' LLJ > COMPENSATION INSURANCE 11 p PLG. C (This section need not be completed if the permit is for one U O hundred dollars ($100) or less.) I certify that in the performance of the work for which this per- QTY. LL U mit is issued, I shall not employ any person in any manner so as to LU become subject to the Workers' Compensation Laws of California. a Date Applicant U) NOTICE TO APPLICANT: If, after making this Certificate of lix- I- Z emption, you should become subject to the Workers' Compensatiun U provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ.C.). Lender's Name 1 d S Ban Lender's Address a 15 1 certify that I have read this rip pplIC alion and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may ' any way ace ue inst said City in conseyr •nee o' the P gr. it' Ig of t is perm - ♦��� MAECH. C Signature of Apl icanl/Contractor n -kr !1, -. ELECTRIC PERMIT FEE :. OUTLETS -SWITCHES - RECEP 5.00/1.00 LIGHTFIXTURES'/1.00 APPLIANCES - RESIDENTIAL 4.00 PANELS 5.00 SIGNS 6.00 SIGNS TRANS. 3.00 SPECIAL CIRCUIT 5.00 TEMP. METER OR POLE INS. 15.00 MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 MISC. - REFER TO ORD PERMIT ISSUANCE 6.00 :ONTR. LIC. NO. ELEC. TOTAL PLUMBING PERMIT ALTER -DRAIN & VENT -WATER (EA.) 4.00 BACK FLOW PROTECT. DEVICE 2.00 DRAINS -FLOOR, ROOF, AREA, COND. 4.00 FIXTURES - PER TRAP 4.00 GAS-EA.SYSTEM-1 INC.4OUTLETS 4.00 GAS - EA. SYSTEM - OVER 4 (EA.) 1.00 INDUSTRIAL WASTE INTER. 20.00 LAWN SPRINKLERS - 1 INC 5 V.B. 5.00 LAWN SPRINKLERS -OVER 5 (EA.) 1.00 SEWER -SANITARY -STORM EA.200ft/8.00 WATER HEATER W/VENT 4.00 WATER SYSTEM 4.00 WATER TREATING EQUIP, 4.00 MISC. - REFER TO ORD. PERMIT ISSUANCE 6.00 ONTR. LIC. NO. PLG TOTAL MECHANICAL PERMIT ALTER OR ADD TO MECH. 4.00 APPLIANCE 4.00 AIR HANDLING UNIT (TO 10M)C.F.M.) 3.00 AIR HANDLING UNIT (OVER 10 C.F.M.) 5.00 EXHAUST HOOD (WITH DUCT) 2.00 HEATING UNIT (TO 100,000 B.T.U.) 4.00 HEATING UNIT (OVER 100,000 B,T.U.)7.50 VENTILATION FAN (SINGLE) 3.00 BOILER -COMPO H.P. or 100,000 B.T.U.) 4.00 BOI LER-COMP lover 100,000 BTU) SEE FEE SCH. MISC. - REFER TO ORD. ERMIT ISSUANCE 3.00 ONT. LIC. NO. MECH. TOTAL ri 01-FICE COvY DA 4800 LIDATION MIT VALIDATIO A Jam/ Ais /- ISSUACF 11 ATE Ity oLE� TIert�% MECH. BUILDING PERMIT INFORMATION VALUAT1oN rice FEE ACC. DATE ZONING FIRE SPR INK Y ❑ N ❑ ACC. FILE NO. ENG. SITE NO. ENERGY T-24 Y ❑ N❑ STORIES TYPE CON FLOOD ZONE Y ❑ N ❑ OCC. GROUP RES. UNI FEE SUMMARY SO. FT. FLOOR AREA TOTAL ACRI BUILDING USE RES IND CON PB ❑ ❑ ❑ ❑ ASSESSORS PARCEL NO. TRACT NO. PARCEI n -� BUILDING PLAN CHECK FEE SEISMIC FEE MICROFILM ELECTRIC PLUMBING MECHANICAL CONST. TAX TOTAL ACC. DATE ZONING FIRE SPR INK Y ❑ N ❑ ACC. FILE NO. ENG. SITE NO. ENERGY T-24 Y ❑ N❑ FLOOD ZONE Y ❑ N ❑ A. L. U. C. Y ❑ N ❑ FEE FEE SUMMARY BUILDING PLAN CHECK FEE SEISMIC FEE MICROFILM ELECTRIC PLUMBING MECHANICAL CONST. TAX TOTAL APPLICAI\j I I U TILL IN INI-UrilVi/k I IUl� VVITHIIV HED LINES -USE [JALL POINT PL -N ONLY . RUP.11171 NG PROJECT I DENTI FICATION PERMIT N t PHONE CONT CT R'S ylrllti \as•P),�yLl� W .y/W, (/{1��J LIC. ADDRESS OR ENGINEER ARCH. OR ENG. LIC. NO. APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING -MECHANICAL( 8 23 LICENSED CONTRACTORS DECLARATION 1 hereby affirm that 1 am licensed under provision of Chapter 9 (commencing with Section 7000) of D inion 3 o h mmess and Professions C e, y license is in Licen Clas Lic. Num Date ��Contracto I OWNER -BUILDER DECL ATION I hereby affirm that 1 am exempt from the ContraFjae,also Law for the following reason. (Sec. 7031.5, Businessar Code: Any city or county which requires a permit to co improve, demolish, or repair any structure, prior to its ELEC, requires the applicant forsuch permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and QTY the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of not more than five hundred dollars ($500).): ❑ 1, as owner of the properly, or my employees will[ wages as their sole compensation, will do the work, and the structure is not 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 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- prove for purpose of sale.). ❑ 1, as owner of the property, am exclusively contracting with 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 contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. ❑ 1 am exempt under Sec. B.&P.C. for this reason Owner Date WORKERS'COMPENSATIV DECLARATION 1 her y affirm that I have a certifi a of consent to self -insure, or a ce I Iicate of Workers'�on1peLls�t ralkcg,pyiLcertified copy th Policy ❑ C '7y Cer App scant division. ELECTRIC PERMIT 1 FEE UTLETS -SWITCHES- RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 APPLIANCES - RESIDENTIAL 4.00 PANELS 10.00 PANELS (OVER 200 AMP) 20.00 SIGNS TRANS. 3.00 SPECIAL CIRCUIT 5.00 TEMP. METER OR POLE INS. 20.00 MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 TEMP. POLE 30.00 MISC. - REFER TO ORD PERMIT ISSUANCE 10.00 :ONTH. LIC. NO. ELEC. TOTAL PLUMBING PERMIT FEE ALTER -DRAIN & VENT -WATER (EA.) 5.00 BACK FLOW PROTECT. DEVICE 4.00 DRAINS -FLOOR, ROOF, AREA, COND. 5.00 FIXTURES - PER TRAP 5.00 GAS- EA.SYSTEM-I INC.4OUTLETS 6.00 GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 LAWN SPRINKLERS- OVER 5 (EA.) 1.00 SEWER -SANITARY -STORM EA. 200ft/10.00 WATER HEATER W/VENT 6.00 WATER SYSTEM 5.00 WATER TREATING EQUIP, 5.00 MISC. - CER-IIFM%TEOFEXEMIT1 FRO WORKERS' PERMIT ISSUANCE COMPENSATIO NSURAN 'E PLG. CONTR. LIC. NO. (This section need not be tom feted if [h permit is for one hundred dollars ($100) or less.) 1 certify that in the performance o he wor for which this er- REFER TO ORD 10.01 PLG. TOTAL mit is issued, 1 shall not employ any per any manner so as to become subject to the Workers' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Ex- 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. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097,Civ.C.). Lender's Name QTY. MECHANICAL PERMIT ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 AIR HANDLING UNIT (TO 10=1C.F.M.) 4.00 AIR HANDLING UNIT (OVER 1Q000C.F.M.) 6.00 EXHAUST HOOD (WITH DUCT) 5.00 HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Address HEATING UNIT (OVER 100,000 B.T.U.)9.50 1 certify that I have res this application and state that the above information is correct. 1 .eto comply with all city and county rdinances and state laws kl4ating to building construction, and ereby authorize represent3tNes of this cit t VENTILATION FAN (SINGLE) 4.00' BOILER -COMP (3 H.P. or 100,000 B.T.U.) 6.00 y o enter upon the DW -Mentioned prop ty fo pection purposes. (We) agree to save, i\,jde,,mNfVand keep harmless the City of pert' agarns[ Gabil ju ents, costs and expenses which y i a way accru inst aid City in consequence of the • BOI LER-COMP (Over 100,000 BTU) SEE FEE SCH. MISC. - REFER TO ORD. PERMIT ISSUANCE 10.00 MECH. CONT. LIC. NO. MECH. TOTAL OFFICE COPY DATE OF APPLICATION IT ISSUANCE DATE LOG . ELECT,, MECH. ❑ ILT" ❑ ❑ , tii*D " A ION ' � ` - JI UMmb TYPE CONSTR. OCC. GROUP RES. UNITS SQ. FT. FLOOR AREA TOTAL ACREAGE BUILDING USE RES IND 13❑ PB ❑ Other ❑ ASSESSOR 'PARCEL NO. TRACT NO. PARCEL NO. ACC. DATE ACC. FILE NO. ZONING ENG. SITE NO. FIRE SPRINK Y ❑ N❑ FLOOD ZONE Y[:] N❑ FEE FEE BUILDING PLAN CHECK FEE SEISMIC FEE MICROFILM ELECTRIC PLUMBING MECHANICAL CONST. TAX TOTAL ENERGY T-24 Y ❑ N❑ A.L.U.C. Y ❑ No ?0