9003 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY "
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
aW LDING APPLICATION & PERMIT 9003/�J
ADDRE O 9 0 0 J
V\ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL V
OWNER' PLAN CHECK VALIDATION
NAME Y. ELECTRIC PERMIT FEE
• l ONE
NAME
s UTLETS-SWITCHES-RECEP 10.00/1.00
NAME 01 ,
LIGHTING FIXTURES 10.00/1.00
CONTRA t Rs LIANCES-RESIDENTIAL 4.00
ADORES ��WQ� I A2 '
I pgpNEms 11E P ELS 10,00 DATE OF APPLICATION
ARCHITECT P NELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
O
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCOR ENG. - SPECIAL CIRCUIT 500 PERMIT VALIDATION
ADDDDRESs .
ZIP EMP.METER OR POLE INS. 20.00
Ars
Acomers MOTORS SEE FEE SCH. 4
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 'r
¢56 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a
w ¢N (commencing with Section 7000)of Division 3 of the Business BLDG. ELECT. PLG. MECH.
H y z Professions Co an license is in full fo t. ❑
Z O a - License Class / Lic.Number ❑ ❑
9 H= w Uate Contractor
¢ OW BUILDING PERMIT
¢ ¢ ,¢a OW R ILDER OECLAR TI N INFORMATION
KO n w 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
w 3 a. y P VALUATION $/FT.
FLL0 < Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 -
Code:Any city or county which requires a permit to construct,alter,
2 ¢ ¢ ,O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.N0, ELEC.'
S c LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
e w mhe is licensed pursuant to the provisions of the Contractor's License
in Law(Chapter 9(commencing with Suction 7000)of Division 3 of the
4 o Business and Professions Code)or-that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toacivilpenalty ALTER-DRAIN -WATER IEA.).5.00
of not more then five hundred dollars($5001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE- 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure isnot -
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such(in
prove.
mentsare not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-i INC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or an- RES NO CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply '
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law, - SEWER-SANITAR V- MEA.200ft/10.00 TRACT NO. - PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER H EATE 6.00
reason'
Owner Date WATER SYSTEM y 5.00
ACC.GATE - ACC.FILE NO.
WORKERS'COMPF-NSATION DECLARATION WATER TRE IP. ' 5.00
I hereby affirm that I have a certificate of consent m self-insure, 'n0 ZONING
ar ertif f ompensa' n I su and e, r cert'i ENG.SITE NO.
copp33yy..��j�t��t11eer L C�
Po IN • C
Q C11 ZZ�rer[i e 'o t reb raishe �5�� FIRE$PRINK ENERGYT24,
Z Z ❑ Tied copy is fl he -ity i ec' n ivi'
H O Arad 'an MISC.- XEVER TO ORD. N❑ V ❑ N❑
CC y CE ICATE OF E 'MPTION FROM WORKERS' PERMIT ISSUANCE 10.00 00 ZONE A.L.U.D.
LL - COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
�' TOTAL
❑ N❑ v [:] N❑
1 his se ion need not be completed if the permit is far one
0 Z hun Ilars($100)of less I
U O 1 certify that in the performance of the work for which this per- QTY, MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE. TO APPLICANT: If,after making this Certificate of Ex-
F 2 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 1Q000C.F.M.) 4.00
la CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MCRM.) 6.00 SEISMIC FEE
it 1 hereby affirm that there is a eanstruction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H
Lender's Address EATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon (he1
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE'SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
C ertino against loVilities,judgments, costs and expenses which CONST.TAX
ay 'n any w ue against said City in consequence a PERMIT ISSUANCE 10.00
ant g o this er i MECH.CONT. LIC.NO. MECH.
' TOTAL TOTAL
Sig e o pl t/Contractor Date
OFFICE COPY