09720 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT I DENTI F[CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT o
ADDHESS
UILDIN
/ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
N ME PLAN CHECK VALIDATION
• a (' _ QTY. ELECTRIC PERMIT FEE
1 ONE ?641V
�r 41 j
,CONTRACTOR S 'U\�/!lam-rF•'(�v'
It�/Ar� I// OUTLETS-SWITCHES-RECEP 10.00/1.00
- { 1 - / (LIc.Nis( LIGHTING FIXTURES 10.00/1.00 .�
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
OORE55
L PANELS 10.00 DATE OF APPLICATION
ARCHITECTon PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH,
DD ESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPILI DDRESS MOTORS SEE FEE SCH. !�
ADDRESS //' (" /
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
is w 1 botchy affirm ()'at 1 am licensed under provisions of Chapter/ ISSUANCE DATE
w G H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH
F y z Professions de an my lineae is in full f r- n4 c 1.
z o w License Claz�Lia Number �.
4 y w Date /7LComrac(or r /
a Y f BUILDING PERMIT
el ¢ a OWNER-BUILDER DECLARATION
A o a O INFORMATION
w g LL I hereby Arm,that I am exempt from the Contras tors License MISC.- REFER TO ORD
r
a_ Law Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VgLDATION S/FT.
Code:Any city or county which requires a permit to construct,alter,
Qaa¢ 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC.
E o LL requires the applicant for such permit to file a signed statement that TOTAL
n w m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Laz ¢ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
E i o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
M m the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(5500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ L as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and (he Structure is not
intended 0,
offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:Pile 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 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees.Provided that such improve-
mentsarenotintendedorofferedforsale.I L however.the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) 200
builder will have the burden of proving that he did not build or im - . - . .
- BUILDING USE
prove Or purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RE5 IND CON PB Omer
❑ 1,as owner of(he property,am exclusively contracting with O
licensed contractors to construct the project(Sec 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS 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
contracts for such projects with a con(ractorls)licensed pursuant to
file Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. B,&1'.C.fur this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'CO.MPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hcmby affirm that I have a certificate of consent to self-irsure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,O a certified
Copy(hereof f m),LAC �����
Pore N6,Cornnanr�ll .
b Cerblied co is Ileruby'funushvd' FIRE SPR INK ENERGY T"24
Z Z YCertifted copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N
F rn PERMIT ISSUANCE 10.00
Lu - CE R"I'IPICATE E SAYI MINS PROM WORK IiRS' FLOOD ZONE A.LU.C.
W 7 COMPot be omINSURANCE PLG.CONTR. LIC.N0. PLG. V N Y❑ N❑
d O (This dollars
need not be completed it the permit is for one TOTAL
� Z huWrtJ dollars[51001 or less)
U O 1 certify that in the performance of file work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
0 U mit is issued1 shall not employ any person in any munnrr so as to
U W became subject
ct to the Workers'Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE '1'0 APPLICANT: II',after making this Certificate of Ex-
F Z emption,you should become subject to the Workers Compensation APPLIANCE _ 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO IOAODC.F.NI) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00ti�
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00 6"1.
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I have read(his application and state that the above VENTILATION FAN (SINGLE) 4.00
infoonation is cormet. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and 80ILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby of
authorize representatives this city to enter upon the
above-mentioned properly forinspectionBOILER-COMP 100,000 BTSEE F �� (�
hipurposes. Over U) EE SCH. MECHANICAL _
(We) afire to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertur6 a, Inst liabilities judgments, costs and expenses which CONST.TAX
�•} may in an way accrue"2gainst said City in consequence of the PERMIT ISSUANCE 10.0017j (/L
(1 gra ti , this permit MECH.CONT. Y LIC.NO. MECH.
I?-/
// r TOTAL _ ,n .
J C" V� TOTAL
ig ate v p ontrxtor Date `.
it
INSPECTOR COPY