C8491 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PEHMIT NUMBER
BUILDING APPLICATION & PERMIT
/DDREss
• 1 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL C-44 91
Ovpx,R'S PLAN CHECK VALIDATION
NAME• PHONE OTY. ELECTRIC PERMIT FEE
NAME \
f " OUTLETS-SWITCHES-RECEP 10.00/1.00
-LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTO 'S " '(
ADDRESS ✓ PPLIANCES-RESIDENTIAL 4.00
/' r PHONE PANELS 10.00 DATE OF APPLICATION
ORCiEC PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No, SIGNS TRANS. 3.00
moo Es8 ENO, SPECIAL CIRCUIT 5.00 's1 PERMIT VALIDATION
as rFEMP.METER OR POLE INS. 20.00
APPLICANT'$ MOTORS SEE FEE SCH. (}IL _ 3 I
ADDRESS
SERVICE CHANGE 20.00 ('
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u I hereby affirm that I am licensed under provisions of Chapter 9 ,p ISSUANCE DATE
mn (commencing with Section 7000)of Division 3 of the Business'and
¢ / BLDG. ELECT. PLG. MECH.
H m i Professions Coda and my license is in full force and off}eJ. ❑ ❑ ❑ ❑
zz 0 w o License Clues/n�__�y>_r Lic.Number3.(�LJC(6
H w Dale T� "��ContractorJ�
1 BUILDING PERMIT .
¢ a OWNEIi.BUILDER DECLARATION
E 0 u o INFORMATION
K
3 u H I hereby affirnh (hal I am exempt/from the Contractors License MISC.- REFER TO ORD
N VALUATION
� uoa Law lot the following reason.(Sec.7031.5.Busincssund Professions PERMIT ISSUANCE 19.0 Hr Code:Any city or county which requires a pemilt mconstn¢t.after,
¢ 2 ¢Q 00
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTRe LIC.NO. ELEC. J O u `�•`
wD LL requires lite applicant tar such permit to file a signed statement that TOTAL �� PERMIT TO
w he is licensed pursuant to the provisions of the Contractor's License
zi Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe �'
a
¢ D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ 1-o the basis for IIIc alleged exemption.Any violation OI'St'CIIVo 7031.5 STORIES TYPE CONSTR.
to by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
El I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP HES.UNITS
sole compensation,will do the work,and Ire structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code T'he Contractor's License Law does not apply loan owner of
property who builds or improves thereon.and who it...weir work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
. himself re through his own employees,provided that such improve- .orients are not intended or offered for sale ll',ed that such
he building IGAS-EA.SYSTEM-1 1PIC.4 OUTLETS JQD Az.�
or improvement is sold within one year of completion, the owner-owner-builder
wner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not huild or ins
prove for purpose ofsalc.). INDUSTRIAL WASTE INTER. 30180 RES IND CON PB Omer
❑ I,as owner of the Property,am exclusively convecting with 0 ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'I he 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
contracts for such projects with contractors)licensed purstmnt to
the Commcmr'slLicense Law. SEWER-SANITARY-STORM EA,200ft/10.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec ,B.@P.C.firs this WATER HEATER W/VENT 6.00
"asoll
pS, Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
t WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1! 1 hereby affirm ZONING that I have a certificate of consent to sal Ginsure.
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thercoffSee 3800,Lab.C.I /1'
Policy No. Company Id Se(,E5"
❑ Certified copy is hereby furmshed FIRE SPRINK ENERGY T 24
Z Z ❑ Cerlificd c pY 's filed VtIr IIIc city inspection division
F -• .
pApplicant .�nasZ 21 4 MISC- REFER TO ORD. Y [] N� Y ❑ NE]
N - PERMIT ISSUANCE 10 FLOODZONE A.L.U.C.
� Clik'I'IPICATIS OF EXEMPTION FROM WORKERS' PERMIT --'
W 1 COMPHNSATION IN$ORANCE PLG.CONTE. LIC.NO. PLG.
-? Z (Phis sactibn need not be completed if the permit Is for one TOTAL O (k Y F] N� Y E 'N❑
hundred d.11...IS 100)or less.)
U O I certify that in the performance of the work fur which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL 1- mit is issued, I shall not employ any person in any manner so as to
O U become subject to the Workeri Compensation Laws of California.
y Datc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING . ./ Ja
} w NOTICE TO APPLICANT: If,after making this Certificate of[is- T _
F 2 emplion,you should become subject to the Workers'Compensation APPLIANCE -5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. / AIR HANDLING UNIT(TO 10MC.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY t AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FE6,
I hereby affirm that there is a construction lending agency for ._EXHAUST HOOD(WITH DUCT) 5.00
the pertoripance of the work Cor which this permit is issued(Sec MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Address
HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Name ELECTRIC
I certify that I have read this application and state that the,base VENTILATION FAN (SINGLE) 4.00
• inl'onuation is correct. I agree to comply with all city and county PLUMBING :Ices
ordinances and slate I��s.relatipy W building construction, anJ BOILER-COMP(3H.P.cr100,000B.T.U.) 6.00 J
hereby authorise repFesentativcs of h my m ever upon the W
�` BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
above-menlione grope y for inspe on purposes.
(We) afire-lb Save mdim if nd kec id, ss the City'of MISC.- REFER TO ORD.
Cupertin ainst 11 /7ities,Ind is, C and expenses which PERMIT ISSUANCE CONST.TAX
may in y way ccrue agra t id C't n consequence of the '-
grand -p mit. . �' MECH.CONT. LIC.NO. MECH. S
TOTAL y 00 TOTAL
c t cl Dale /
,10 INSPECTOR COPY
I