12242APP,_ICANT TO FILL IN IN RMATION WITHIN RED LINES - US ALL POINT PEN ONLY
BUILDING PROJECT IDENTI ION
APPLICATION &P RMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
12242
�IOULOING
ADDRESS L
o J1CvS
OWNER'S -
"`- [� -� _
ry T {/� PHONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
coNTRA .DR's
NAME
a. Nr- LIC. No. /90 61%,z?
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.0011.00
CONTRACTOR/�7J ✓5 T/¢/A•4, 9D,
IS PHONE - ip
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT-
OR
ENGINEER
. uc. No,
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.
ADDRESS
ZIP
SPECIAL CIRCUIT 5.00
+�j�LIDATION
P `��
oEC 2 21986
of &A" b�T
ISS. NCE E
TEMP. METER OR POLE INS. 20.00
APPLICANT'S/ jDa /AI�005?z2//s1. zQ�.
ADDRESS
-.rjAA/ CA12V-p,t4 5% O70
MOTORS SEE FEE SCH.
ISERVICE CHANGE 20.00
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, rFI r license is in full force' J e e
License Cie s- ' 1.v Lie. Number.
Dale Contractor- _
OWNCR-BUILDER DECLARATION
I hereby altar that 1 aim exempt from the Contractor's License
Law for the following reason. (Sec. 703 [.5, Business and Professions
Code: Any city or county which requires, permit toconstowt, alter,
improve, demolish, or repair any strucpve, prior to its issuance, also
requires the applicant for such permit to file o signed statement that
he is licensed pursuant to the provisions of the Contractor License
Law (Chapter 9 (commencing with Section 700(Yof Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
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 (5500).):
❑ 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
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-
mentsarenolintendedorofferedforsale. 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.).
❑ I, 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 contraclor(H licensed pursuant la
the Contractor's License Law.
❑ I am exempt under Sec. JLAI'.C. for 111 is
reason
-
BLDG. ELECT.
❑
PLG.
❑
1. Riftcu.
BUILDING PERMIT
INFORMATION
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
vgLUATION
$/FT.
ELEC. CONTR. - CIC. NO.
ELEC.
TOTAL -
ERMIT TO
DTV. PLUMBING PERMIT FEE
STORIES-
TYPE CONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
FIXTURES - PER TRAP 5.00
So. FT. FLOOR AREA
TOTALACREAGE
GAS - EA. SYSTEM -11 NC.4 OUTLETS 6.00
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS -I INC 5 V.B. 6.00
-
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
SEWER -SAN EA. 200ft/10.00
TRACT NO,
PARCEL NO.
WATER HEATER W/VENT 6.00
Owner Dare
WATER SYSTEM 5.00
ACC. DATE
ACC FILE NO.
WORKERS'COMPENSATION DECLARATION
1 hereby affirm [hat I have-acerlifealeofconsent IOself-insure,
or a certificate of Workers' Compensation Insurance, or a certified
copy thereoft$ec. 3800, Lab.C.) A 7J!
Policy No. Company
❑ Certified copy Is hereby famished.
fyCurtifieJ copy is Bled with the p Sion.
Applicant
WATER TREATING EQUIP. 5.00
ZONING
ENG. SITE NO.
FIRE SPRINK
Y❑ N❑
ENERGY T-24
Y❑ N❑
MISC.- REFER TO ORD.
%1 7 O6o) O 5OPERMIT
C17RTIFICATE OF EXEMPT ON FROM P 'Ii RS'
COMPENSATION INSURANCE
This section need not be completed if time permit is for ane
hundred dollars ($100) or IESS) '
1 certify that in the performance of the work for which this per -QTY.
mit is issued, 1 shall not employ any person in any manner No as to
become subject to the Workers' Compensation Laws of Culililrniu.
Dee Applicant
ISSUANCE 10.00
FLOOD ZONE
Y ❑ N ❑
A.L.U.C.
Y ❑ IN
PLG. CONTR. LIC. NO,
PLG.
TOTAL
' MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 5.00 3,61
NOTICE '1'0 APPLICANT: 11, after making this Certificate of Ex.
emptinn, you should become subject to the Workeri Conmpensation
provisions of the Labor Code, you must forthwith comply with
inch provisions or this permit shall be deemed revoked.
CONSTRUCTION.LENDING AGENCY
I hereby affirm that Ihere is a construction lending agency let
the performance of tile work for es )m this permit is issued (Sec.
3097, Civ.0.).
Lender's Name
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10=11F.M.) 4.00
AIR HANDLING UNIT (OVER 10MC.F.M.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lenders Addre>s-
I certify that I have read this plication and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating t0 building construction, and
hereby authorize representatives of this city t0 emei nom, the
above-mentioned property for inspection purposes.
(We) agree t0 s' e, judo mify and keep harmless the City of
Cuperti against 1' ties, I Idgmenls, costs and expenses which
I a ay ue ago' est said City in consequence of the
•mI g this PC L -
o /2=L7��
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER -COMP (3 H.P. of 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU( SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO. MECH.
TOTA� O O
TOTAL
.,a.=,
g na are of lican Contractor Date
OFFICE COPY