13359 JUL 2 01987,
APPLICANT TO FILL IN INFORMATION WITHIN R.ED LINES - USE BALL POINT PEN ONLY
.'BUI EDI NG PROD T 1 D NTI F CATI - PERMIT NUMBER
BUILDING APPLICATION &-PERMIT "
ADDRESS 1 335.9
' BUILDING -ELECTRICAL-PLUMBING--MECHANICAL
ti✓ °WrvEHIS B�J�'tr/� < s r , ,, $ r, PLAN CHECK VALIDATION
'1}, NAME ��f••� QTY•, ELECTAIC`FERMIT' FEE.
'i
1 PHONE
oNTRACTORsOUTLETS-SWITCHES-'R ECEP 10.00/100
` A N �✓r /YN�N'GIe No. LIGHTING FIXTURES 10.00/1.00 -
CONTRACTORS0 APPLIANCES-RESIDENTIAL 4.00 .
ADDRESS ,
DO� PHONE PANELS 10.00 DATE OF.APPLICATION
ARCHITECT - PANELS (OVER 200 AMP) .,, -'-20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER '
3.00
LIC.No. SIGNS TRANS,
ARCH.OR ENG. SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ADDRESS -
'
zip EMP.METER OR POLE INS. 20.00 "
o
APPLI - - ' MOTORS SEE FEE SCH. ', ,�
ADDRESS
• SERVICE CHANGE - 20,00 //q �•
woo LICENSED CONTRACTORS DECLARATION 0, 7/0 7
rc v u 'I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE'
r ae "' (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT.. PLG.. MECH.
H�i Professions C of tic'yr�}is in full forte fro.Z
o 0 c2 o License Class�h c.Number Ll ❑ ❑ ❑,
Date Contractor
a, a x f ". BUILDING PERMIT
a ¢ OWNER-BUILDER DECLARATION .'INFORMATIONS,
M 6 0 a`a REFER TO ORD
w ; LL r 1 hereby affirm that 1 am exempt from the Contractor's License MISC.-
u0er Law for the following mason.(Sec.7031,5,B usiness and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
w N Code:Any city or county which requires a permit to construct,alter,
¢ al Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
LL- requires the applicant for such permit to file a signed statement that - TOTAL PERMIT TO
d w m he is licensed pursuant to fire provisions of Ore Contractor's License y ,
rzi
Law(Chapter 9(commencingwith Section 7000)of Division3ofthe x mac •*
¢ Business and Professions Code)or that he is exempt therefrom and OT�Y.. 'aFLUMBINGIPERMITz .F,EE
¢ the basis for the alleged exemption:Any violation ofSection 7031 S �. 8- s s' " ^. �< ° STORIES TYPE CONSTR.
a 3 .- by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred.dollars($500).):
❑ 1,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 the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
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 5.00 - So.FT FLOOR AREA TOTAL ACREAGE
Pail himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 6.00 ,
m encs are not intended or offered for sale.If,however,the building
or impmp
rovement is sold within one year of coletion,'the one
wr-
GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or in,-
prove 1,as owner
of sale.). RES IND CON PB 1:1
INDUSTRIAL WASTE INTER. 30:00
❑ d as owner of the property,he exclusively contracting with - ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. oBusiness LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
d
and Professions Code:The Contractor's License Law does
not apply
to an owner of property who builds to improvesensed n,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with o wntracmgs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT N0. PARCEL NO.
❑ Iamexemptunder Sea ,B.&P.C.for this WATER HEATER W/VENT 6.00 -
mason
Owner Date WATER SYSTEM5,00
ACC.DATE ACC.FILE NO.
WO /y�/BL���jpp��jF/�1/5��.7/�p��DECLARATION- WATER TREATING EQUIP. 5.00
I hereb afRfnr TOatY 115v!•TceRdl�ale of consent to self-ireure, ZONING ENG.SITE NO.
ora cerci ate of Workers'Compensation Insurance,or a certified _
C. 0rere fSee.3800,Lab.CJ.
Policy No. Company /V
0 ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGYT-24
Z Z �K Certifi co y is filet', h ��/�ty p cti di Ision.
p Applicunl�QL041a tNl. f'/Y -� MISC.- REFER TO ORD. Y ❑ N❑' v ❑ N❑
T CERTIFICATE OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE a.L.u,c. '
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. - PLG.
CL 0 (This section need not be completed if the permit is for one TOTAL v❑ N❑ Y❑ N❑
Z hundred dollars($100)or less.) -
U,O I certify that in the performance of the work for which this per CITN,a „*s ;i` MECHANICAL PERMIT a "a r FEE' - FEE SUMMARY
- tLL mit is issued,I shall not employ any-person in any manner so as to
become subject to the Workers'Compensation Laws of California
0 w Dale IA Applicant - - BUILDING
CL PI - ALTER OR ADD TO ME 5.00
•} m NOTICE TO APPLICANT: If,'after making this Certificate of Ex-
L.. ? emptlon,'you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY ' AIR HANDLING UNIT(OVER 10p00C.FM;) 6.00 SEISMIC FEE
I hereby affinn'that there is a construction lending agency for EXHAUST HOOD((WITH DU T'))P, 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ, HEATING UNIT(TO 100,0 �A.T.UJ 8.00
Lender's Name -
Lender's AddreHEATING UELECTRIC
I C
N IT EF1100,000 B.T.U.)9.50 '
r ¢tom
ss
pP' I Certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
x information correct. 1 agree to comply with all city and county PLUMBING
q ordinances and state laws relating to building construction, and BOILER-COMP I3 H.P.DP 100,0008.T.U.) 6.00
('$ hereby authorize representatives of.this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cup Iino a,aiIabilities,judgments, costs and expenses which CONST.TAX
tre against said Cityin consequence of the PERMIT ISSUANCE 10.00lt. //////�I ECH.CONT. LIC.NO. MECH. r
TOTAL TOTAL
SigfiatuieYrXpplicant/Contrctor R/ D m �" . �
OFFICE COPY - ,