10941AVPLICANT TO FILL IN INFORMALT.ION WITHIN RED LINES - USE BAIL POINT PEN ONLY
BUI LDI NO PROJECT 1 DENTI FICATICW -
APPLICATION &PER
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
10941
BUILDING
BUILDING _
6
OWNER'S
NAME
/
/'7/PLCii )PGY.1/( - PHONE��'�i)�O
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTORS
NAME
UTLETS -SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
LIC. NO,
CONTRACTOR'S
ADDRESS
-RESIDENTIAL 4.00
PANELS 10.00
PHONE
DATE OF APPLICATION
ARCHITECTPANELS
OR
ENGINEEfl
LIC. NO.
(OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. - 3.00
AARC"
DDREOR SS ENG.
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
zap
_- J
p Ap,r4-r"
nnn A7�j�
APPLICANT'S
ADDRESS
L -
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSE/D.,COA RS ATIONHr1A
I hereby of provisions of Chapter 9
Ba
) f Division 3 of the Business and
PIOI'e5 L'se rs m full force and effect
lass Lic. Number
ISSU NCE D TE(Comment
BL
Eo MECH.
El El
Dale Contractor
BUILDING PERMIT
OWNER -BUILDER DECLARATION
I herebyaffirm that I am exempt from the Contractor's License
P
Law foring ounty whiche.uires perminess t to Professions
the Any
Code: Any city county whiny structur a permit to cons ua ce, lter,also
improve, demolish, or repair any structure, prior its issuance, also
INFORMATION
MISC. - REFER TO ORD
VALUATION
/�
/ AoO,
!/"
$/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. N0.
ELEC.
n
requires the applicant for such permit to Elle a signed athat
he is licensed pursuant to the provisions of the Contractor'sctor's License
TOTAL
PERMIT TO
DTV. PLUMBING PERMIT FEE
usi (Chapter 9 (commencing with Section of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
Bis exempt
the basis for the alleged exemption. Any violation of Section 7031.5
BTORIE
YPE DN$TR.
by any applicant for a permit subjects the applicant toa civil penalty
of not more than five hundred doll.. ($500).):
ALTER-DRA I N & VENT -WATER (EA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00ace
. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
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 (hereon, and who docs such work
FIXTURES -PER TRAP 5.00
SO FT. FLOOR AREA
- TOTAL ACREAGE
himself or through his own employees, provided that such improve.
ments are not intended or offered for sale. If, however, the building
GAS - EA. SYSTEM -1 INC. 4 OUTLETS 6.00
or improvement is said within one year of completion, the Owner-
builder will have the burden of proving that he did not build or im
for purpose of sale.).
❑ I, as owner of the properly, am exclusively contracting with
GAS - EASYSTEM -OVER 4 (EA) 200
. ..
BUILDING USE
R No CON PB Ono,
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
licensed contractors to construct the project (Sec. 7044, Business
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 IEA.) 1.00
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License L
SEWER -SAN V -STORM EA. 200tt/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
❑ lamexemplund Sec. .B.&P.C. for this
Owne - to
WATER SYSTEM 5.00
ACC.DATE
ACC. FILE NO.
WORKERS'NMPIIENSATION DECLARATION
WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self -insure.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE N0.
copy thereof (Sec. 3800, Lab.C.).
Policy No. Company
_
❑ Certified copy is hereby furnished.
FIRE SPRINK
ENERGY T 24
❑ Certified copy is filed with the city inspection division.
Applicant
Y ❑ N❑
Y ❑ N[3
MISC- REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOODZONE
A.L.V.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y F] N ❑
Y C] N❑
QTY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH. 5.00
FEE SUMMARY
hundred dollars ($100) or less.)
1 certify that in the performance Of the work for w this per,
mit is issued, I shall not emplo person in an an so as to
bum a ec he Worker pe ifor'
an
Dat APPLICANT:IL after making s Ex
NO PPLd
BUILDING
qpp LIANCE 5.00
PLAN CHECK /
sa
become Workers' Compensation
empision you should become subject to Workers' Cco poly
must with
provisions io the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE /
AIR HANDLING UNIT (TO 10,000GF.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a cent n en1f1-ding agency (or
the performance of the wh' It permit is issued (Seca
3097, Civ.C.L a
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATI NG UN IT (OV ER 100,000 B.T.U.) 9.50
ELECTRIC
Lender' a
L r s ddress
A
VENTILATION FAN (SINGLE) 4.00
PLUMBING
1 certify that I have read this application and stale that the above
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
BOILER-COMPI3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
( e) agree to save, indemnify and keep huntress the City of
C ertino against liabilities, judgments, costs and expenses which
any way inst said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
MECN. CONT. LIC. NO. MECH.
of Of this p m' .
TOTAL
TOTAL
6L9
agoof Icant/Contractor- Date'
OFFICE COPY