5019APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NO PROJECT I DENTI FICATION
APPLICATION &PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NOMBFR
- 501 n
LD -/Oo
A ..E G a3 S-
s A. _�• �'u,�.0
/7✓�
OWNER'S
NAME
SOC�a, c /wl PHONE/O T
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTORS
croR's -
LIC. NO. -
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S
ADDRESS
miONE
APPLIANCES 4.00
'PANELS 5.00
ARCHITECT
O
OP
ENGINEER.
' uc. NO
SIGNS 6.00
PLAN CHECK FEE P. C. NO,
SIGNS TRANS. 3.00
noir ESS EN¢
• ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATIOLI ) /
ISSUANCE DATE
rrEMP. METER OR POLE INS. 15.00
AS
ADDREDDRESSS
-
- MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 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
Class Lic. Number
Dale Commclo,
OWNER -BUILDER DECLARATION
Contractor's eiceree
hereby collo that I am exempt from the Businessman
Code:Law Any citylowing Teasonch requires a permit essand Professions
Code: Any cors my whiny structure permit t toconstruct.issuance.
lter,also
improve, demolish,cplicOr for sir can y structure, e ass Ind SIatemet, also
lie is les Ilse llpp rsomant for the permit 10 of to signed actor's Li ensethat
he is licensed 9 (com+l en the provisions of the )ofDivmr's 3 of ase
of Division 3 of the
Law (Chapter r f commencing wish Section is exempt
Business and Professions Code) or that he is exempt therefrom and
by hares for the alleged exemption. Any i applica of Section 701lty
by any applicant fora permit dollars S5000.licae toacivil penally
of not more Than five hundred dollars (5500).):
❑ I, as owner of the properly, or my employees with wages as
sole compensation, will do the work, and the structure is nor
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,
Code: The Contractor's License Law does not apply to an owner of
property Wlso builds of Improves thereon;and who does such work
himself or through his own employees, provided that such improve.
mems are not intended or offered for sale. IG however, the building
or improvement is sold within one year of completion, the owner -
builder will have the burden Of proving that he did 1101 build or im;
pr for purpose of sale.).
•f➢ I, as owner of the property, um exclusively' contracting with
licensed contractors to construct the project (Sec. 7044, Business
and Professions Coda:'I'lie Contractor's License Low does not apply
to on owner of p,.Perry who builds 0u Improves thereon. and who
contracts for such projectswith a Comrumons) licensed pursuant to
the Contractor's License Law,
-❑ lam erlmp�r rSec,o._1 ,8..li
O �� A n
BLD PLG. MECH.
❑ EJ 1:1License
QED ERMIT
I INFORMATION
MISC.- - REFER TO ORD
PERMIT ISSUANCE 6.00
+�
CiglWfino-
Ev OWWT/"`VVV
/
SIFT.
ELEC. CONTR. LIC. NO. ELEC.
TOTAL
QTY. PLUMBING PERMIT FEE
PERMIT TD E
/LfQL/
�s / AC UG'%U.f�J
STORIES
TYPE CONSTR.
'
ALTER-DRAIN-WATER(EA.)4.00
BACK F LOW PROTECT. DEVICE 2.00
OCs. GROUP
RES. UNITS
ROOF, AREA,CON D. 4.00 .
FIXTURES - PER TRAP 4.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -1 INC.4 OUTLETS 4.00
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB oma,
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
_
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT No.
PARCEL NO.
'
WATER HEATER W/VENT 4.00
-Datereason
WORKERS'COMPENSATIUN DECLARATION
1 hereby affirm that I have a certificate of consent toself-insure.
or a certificate of Workers' Compensation Insumnce.,ar a certified
copy thereof (Sec. 3900, Lab.C.).
Policy No. Company
❑ Certified copy is hereby furnished.
❑ Certified copy is fled with the city inspection division.
Applicant -
WATER SYSTEM 4.00
ACC.OATE
ACC. FILE NO,
WATER TREATING EQUIP. 4.00
ZONING
ENG. SITE NO.
_
FIRE SPRINK
Y ❑ N❑
ENERGY TYA
Y ❑ No
MISC. - REFER TO ORD.
CERTIFICAIE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('Phis section need not be completed if the germ it is for one
hundred dollars(n the pe less.)
I certify that in the performance at the work for which this ger-
not R issued, I shall not employ any person In any 11IDI11ICT SO !IS to
become subject to the Workers' Compensal ion Laws of California.
Data Applicant
NOTICE 1'0 APPLICANT'. It, offer making this Certificate of lex-
em plion, you should become subject to the Workers' Compereution
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
CONS'fRUCI'ION LENDING AGENCY
I hereby affirm that there is a construction lending agency lot
the performance of the work for which this permit is issued (Sec
3097. Civ.C.).
N
Lender's Name
Lender's Name
I certify tlmtl have read this applicmion unAslate thal the above
information is correct. I agree to comply with all city and county
jordinances and slate laws relating to building construction, and
!hereby authorize representatives of tits city to enter upon file
above-mentioned property for inspection purposes. '
(We) EST a to save, indenTnify and keep hermiess the City of
Cugertinoainsl liabilities, judgments, vases and expenses which
may in y w, {{ aecr agnins sue City in canscquunce I' the
Efon'
PERMIT ISSUANCE 6.00
FLOOD ZONE
Y N
❑ ❑
A.L.U.c.
Y N
❑ ❑
PLG.CONTR. LIC. NO,
TOTAL
DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
`r
ALTER QR,ADD TO MECH. 4.00
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10=1CF.M.) 3.00
PLAN CHECK
FEE
AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00
SEISMIC FEE
e3�
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER-COMP13 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP IOver 100,000 BTU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
CONST. TAX
pERM1T ISSUANCE 3.00
MECH. CONT. LIC, NO.
TMECH
OTAL
-
TOTAL
T
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S' mturc of Appllaanl/Conlmc or Dolc
OFFICE COPY