4868 APPLICANT TO FILL IN INFORMATION WITHIN. RED LINES - USE BALI.POINT PEN ONLY
FERMI NUMBER
BU I LDING PROJECT I DENT[FICATI ON APPLICATION & PERMIT 4868
BUILDING
' /OGRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANIC
' - OWNER'S . -- PLANCHECK VALIDATION
NAME /�����/e (A/ QTY. ELECTRIC PERMIT FEE -
r 1 /- PHONE , Y
CONTRACTOR'S
NAME ��r� OUTLETS-SWITCHES-RECEP 5.00/1.00
:Z rg(/' T i&6C.No. /V LIGHTING FIXTURES 5.00/1.00 - -'
ADDRESS Rs PPLIANCES-RESIDENTIAL '4.00
'KGkDI,� PHONEPANELS 5.00 jpATE OF APPLICATION
ARCHITECT PLAN CHECK FEE: P.C.NO.
OR- - SIGNS 6.00 -
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCIT OR
r
ADDRESS ENG SPECIALCIRCUIT - 5.00 - PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00 -
APPLICANT'S - I
ADOREss MOTORS SEE FEE SCH. 1 I
SERVICE CHANGE10.00 Il1l I0 `
o o LICENSED CONTRACTORS DECLARATION _
a v w I hereby affirm that I am licensed under provisions of Chapter 9 I&6 NCE DATE
y< (commencing with Section 7000)of Division 3 of the Business and LD ELECT. PLG.. - MECH.
i Professions Ce� a�ndd�����1�Ilicense is in full fur ❑ .❑ - ❑
z'o n - License Class 4 •7__1_Lic.Number V
4 r Date_0 /.- •i Contractor IELEC.CONTR.
/! yt - BUILDING PERMIT
`a s / 7/--s9 -- o C 0 0- - iIS m ¢ a OWNER-BUILER D ARATIa o n`° MISC.- REFER TO ORD INFORMATION
x ; LL I hereby affirm that I am exempt from the Contractor's License-
La Law for the following reason.(Se,7031.5,Business and ProfessionspERMITdSSUANCE 6.00VALUATION $/FT.
Code:Any city or county whichrequiresapermittoconstruct,alter,p Q 0 Improve,demolish,of repair any structure,prior to Its Issuance,also' LIC.NO. ELEC.al LLrequires the applicant for such permit m file a signed statement that TOTALwm he is licensed pursuant to the provisions of the Contractor's License ERMIT TO
ca Law(Chapter 9(commencingwlth Section 7000)of Division 3 oftle E o Business and Professions Code)or that he is exempt therefrom and PLUMBING PERMIT FEE
+ X r $ the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CJ)NSTR.
i 3 by any applicant for a permit subjects the applicant too civil penalty
of not more than five hundred dollars(S500)): ALTER-DRAIN& VENT-WATER(EA.) 4.00 V
O 1,as owner of the property,or my employees with wages asggCK FLOW PROTECT. DEVICE 2,00 eao 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 /' p+j ��7
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACR GE
himself or through his own employees,provided that such improve "
menu are not intended or offered.for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA:) . 1.00 euaOlNc USE
builder will have the burden of proving that Ire did not build or an- 5 IND CON P
prove for purpose of sale.)' I NDUSTR IAL WASTE/NTER. - 20.00 S Omer
❑, 1,as owner of the property,am exclusively contracting with Q E -El Q
- licensed contractors to construa.the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 .gggEssoas 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 pgfp
contracts for such projects with a comruclor(s)licensed pursuant to -
theContractor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT q NO.. PARCEL NO.
O I um exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT. 4.00 JQIV' 11 �. ,
reason
Date Owner WATER SYSTEM ' 4.00. ACC.DATE ACC:FILE NO.
WORKERS'COh1PENSATION DECLARATION WATER TREATING EQUIP. - 4.00 City Of Cupe Ino
- I hereby affirm that I have a certificate ol'consent to self-insme, .ZONING ENG.SITE NO.
or'a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.CJ.
Policy No. Com pony -
❑ Certified copy is hereby famished FIRE SHRINK ENERG Y7-24F- ,
Z Z ❑ Certified copy Is filed with the city inspection division.
p Applicant MISC.'- REFER TO ORD. YE] N❑, y N[:]�+ PERMIT ISSUANCE 6.00
W - CERTIFICATE OFON FROM FLOOD ZONE A.L.u.C.
PLG
CLO (This section need not be completed SJRftl ehpennit is for one PLG.CONTR. LIC.N0. TOTAL V N Y NE] '
Z hundred dollmi,($I00)or less.) Ed
L) O 1 certify that in the performance f the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY-
, LL F- mit is issued,I'shall not employ a person in any m ner so m ro
U . beco e s the Worke ansa ion .[if T
O w Date �- AX WN.r BUILDING
n ALTER OR ADD TO MECH: 4.00 O
.} a) NO C8 TO A PLICANT: after makin this'Certificute C Ex- .._
,F 2 emptlon,you should became subject to the orktrs'OOInpC cation APPLIANCE _ 4.00 PLAN CHECK
.provisions of the Labor,Cade, you must forthwith comply with FEE
U such provisions or this permit shall be deemed'revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 M
CONSTRUCTION:LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE 7�
I hereby affirm 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. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NO UNIT 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE)' 3.00 .-
-� information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.of 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for Inspection purposes. 801 LER-COMP(Over 700,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and,keep harmless the City of MISC.= REFER TO ORD. _
- Cuperti against liabilities,judgments,costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may i ny.way accrue against said City in consequence of the "
grmfl of thispermis MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL 51 (K
/ ignature of A licant/Contraclo 'Date a
OFFICE COPY