6806!APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL P:i4JT REN ONLY
BU LDI NG PROJECT I DENTI FICATI ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
6806
BOtLDING
nDEARESS `OO Vi
owNEVS
PLAN CHECK VALIDATION
NAME
-:
PHONEOJ -13/ .
QTY. ELECTRIC PERMIT, FEE
DATE OF APPLICATION
CONTRACTOR
NAME /� J�1
�} su I� $ uc. rvo. Gy l
UT LETS' SWITCHES -RECEP 5.00/1.00
UT
TING F IXTURES 5.00/1.00
ADDRESS ons
878, CONTRACTOR
.fpy p CC
�y. !0f - e PHONE OrOV �4"UJ
M.
- RESIDENTIAL 4.00
APPLIANCES�(//p�
PANELS 5.00
ARCHITECT
OR
ENGINEER
LOC. No.
SIGNS 6.00
PLAN CHECK FEE P.C. N0.
SIGNS TRANS. 3.00
ARCH.08 ENG. -
ADDRESSZIP
SPECIAL CIRCUIT 5.00
PERMIT VALI DATION
TEMP. METER OR POLE INS. 15.00
AS
ADDREDDRESSS
MOTORS SEE FEE SCH. '
SERVICE CHANGE -PAID 10.00
LICENSED CONTRACTORS DECLARATION
'
NI �I 1 1964
I hereby aflinn Itm, I am licensed under provisions of Cmp(c, 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
Professions CoJsy,�nd ry license is in full fortyq Y -
License C {xs.1.:� Lie. Number �,�3
Date_ /_a1- z Contmetor (2Q$. !%!
-
'BLDG.
❑
ELECT.
PLG. MECH.
❑ ❑
x-�� city f` r In
BUILDING PERMIT '%:
l a
OWNER -BUILDER DEC'LA RA'T'ION
I hereby aflinn that I am exempt from the Coactor's License
Law for the following reason. (See. 7031.5. Busntrinessand Professions
Code: Any City m 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 We provisions ol'the Contractor's License
Law (Chapter 9(commencing with Section 7000) ofDivision 3 of 'the
Itusine.o and Professions Code) or that he is exempt tee®front and
INFORMATION
MISC. - R FE TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 6.00
ELEC CONTE. LIC. NO.
ELEC. _ r�
TOTAL pry'-
%
PERMIT TO
�H�• E G7
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
T''hash fnr We allege.) exemption. Any violation of$e[tion 7031.5
ALTER -DRAIN & VENT -WATER (EA.) 4.00
by any applicant for a permit subjects the applicant o a civil penalty
of not more than five hundred dollars ($500).):
❑ h as owner of the property, or my employees with wages as
their sole eompenution, will do the work• and the structure Is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. 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
FIXTURES - PER TRAP 4.00
SD. FT. FLOOR AREA
- TOTAL ACREAGE
himself or through his own employees, provided that such improve
mems are not intended or offered for sale. IL Iowa,,,, the lolkling
GAS-EA.SYSTEM-l1NC.40UTLETS 4.00
ur improvement is sold within one year of completion, the owner-
e did not ld or inu-
builder will have the burden of proving that hbui
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
licatsed contractors to construct the project (Sec. 7044, Business
and Professions Code: *the Contractors License Law does not apply
to an owner of property who builds or improves thereon. and who
. ..
GAS - EASYSTEM -OVER 4 (EA1 100
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
Contracts for such projects with a contractor(s) licensed pursuant In
the Contractors License haw.
SEWER-SANITAR V -STORM EA. 200it/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
❑ I am exempt under Sec,-. B &P.C. I'or this
son
Owmu Date
WATER SYSTEM 4.00
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORK 1: RS'COM PENSA'1'ION DECLARATION
I hereby affirm that I have a Certificate Of consent losell-insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
ropy therepql( $��y'�sss'ssss] b. Lab I-
I'ollcyNo.iany_ n1S,
❑ Certili• pY ucmby ish
❑ Cerof fie h pection Division.
Applican
FIRE SPRINK
V ❑ N ❑
ENERGY T-24
V ❑ N❑
MISC.- REFER TO ORD.
PERMIT ISSUANCE 6.00
FLOOD ZONE
A. L.U.C.
CFR1'IFICA'I'Ii OF EXEMPTION PROM WORKERS'
PLG.CONTR. LIC. NO.a
PL LG.
TOTAL
COMPENSATION INSURANC17
(This section need not be completed if the permit is for of re
Y❑ N❑
Y❑ N ❑
QTY. MECHANICAL PERMIT FEE
s.
FEE SUMM:4RVt'.7sP
hundred dollx IS 100) m less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner sn as to
BUILDING
become subject to the Workers' Compensation Laws of California.
Date APplicaut
ALTER OR ADD TO MECH. 4.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
eniption, you should become Subject to We Workers' Compensation
provisions of the Labor Code, you must forlhwith comply with
such provisions or this permit shall he deemed revoked.
APPLIANCE 4.00
PLAN -CHECK
FEE
AIR HANDLING UNIT (TO 10=C.F.M.), 3.00
AIR HANDLING UNIT (OVER 10,000C.F.M.) 5.00
SEISMIC FEE
CONS']RUCTION LENDING AGENCY
EXHAUST'HOOD (WITH DUCT) 2.00
MICROFILM
I hereby aflinn that there is a construction lending agency for
01e performance of the work for which this permit is issued (Sec.
3097, Ce.C.l.
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
I cerlily that l 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
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILEfl-COMP13 H.P. or 100,000 B.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 Lope Ho purposes.
(We) fierce to Save, indent n' y u 'keep harmless the City of
Cuperti gatest mbilities, js gate is, Costs and expenseswhich
May wa a st S' City in onsequence of the
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO. TOTAL
TOTAL
accrue
CIS t 1 it. ,ry�
OX
ib a arc ol'Applic%'i(1nt Cnntranor Date
OFFICE COPY