13564 -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
vl BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
BUILDING APPLICATION & PERMIT 013 5 6 4
A DR , 1 / BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
1.NER'ko (/ gIVE PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
Z�U�/C^ PHONE
CONT ACTDRS OUTLETS-SWITCHES-RECEP 10.00/1.00
N LIC.No. '(7zZ LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS �XDQ���
-)QQ PHONE (S ZS PANELS 10.00 DATE OF APPLICATION
ARCHITECT S.J . 9sraa PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00 }
APPLICANT
DD.ESS TS MOTORS SEE FEE SCH. J
SERVICE CHANGE 20.00 ,
a o O LICENSED CONTRACTORS DECLARATION I �/ ;,
<U w 1 hereby affirm that 1 am licensed under provisions of Chapter 9 's�G -ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PMECH
z i LG.Professions Codf.randd my license ism full forCt YP f�1. /s
z o y - License lass-(„�G,(�Lic.Number IQ�f yl r1�+-, (t ME]O z - o Date Contractor
< y f r
¢ ce < OWNER-BUILDER UECL ION BUILDING PERMIT
¢w INFORMATION
o A U MISC.- REFER TO ORD
X 3 a.y 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
H w 0 A Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
m i I Code:Any city Gloomily which requires permit to construct,alter,
¢ K <O improve,demolish,or repair any structure,prior to its issuance,also $LEC.CONTE. LIC.NO. ELEC.
- O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
X$ m he is licensed pursuant to the provisions of the Contractor's License
Fz >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
- < Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
K F¢-o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A. by any applicant forapermitsubjectsthe applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($501
❑ 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 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 F IXTUR ES-PER TRAP 5.00 a0.FT.FLOOfl AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
meals are not intended or offered forsal,If,however,the building GAS-EA.SYSTEM-11NC.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 am- RES IND CON PB Omer
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 conlraclot(s)licensed pursuant to
SEWER-SANITAR V-STORM EA.200ft/10.00 ,TRACT No. PARCEL No.
the Contractor's License Law.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 '
I hereby affirm that I have a certificate of consent t0 self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is Bled with the city inspection division. MISC.- REFER TO ORD.
O Applicant .Y ❑ N❑ V ❑ NE),
W CERTIFICATE OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 C.
UJ > COMPENSATION INSURANCE - PLG.CONTE, LIC.NO. PLG, v❑ N❑ YE] N❑
1 0 (This section need not be completed if the permit is for one TOTAL
::) Z hundred dollars($100)or less.)
U 0 I certify[hal in (he performance o m wo f hich this per OTV MECHANICAL PERMIT FEE FEE SUMMARY
U_ F- our is issued,1 shall not employ a Don' nanner sn as to .r
U becom a cl se Workers'C ti a of C0frmia. BUILDING
U i DmeApplicanl ALTER OR ADD TO MECH. 5.00
} N NOTI A [CANT: If, er an.kirrMIS Certificate of 13x- -
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 10MC.F.M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQ QF.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. t MICROFILM
3097,Cie.0.). ' HEATING UNIT(TO 1 4,000 B-T.UJ-8.00
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U. ELECTRIC
Lender's Address
I certiIV
fy"that I have read this application and slate that the above VENTILATION FAN (SINGLE) COPL 410b
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 lite BOILER-COMP Over i00,0006TU1 SEE FEE SCH.1 MECHANICAL 00
above-meNion roperly for inspection purp0 •.
(We) ee save, indemnify and kee It ess the City of MISC.- REFER TO ORD.
Cuperti a
a
t "ITC ,judgments, st nd expenses which CONST.TAX
may wagai t n consequence of he PERMIT ISSUANCE 10.00
gran of this MECH.CONT. LIC.NO. MECH.
TOTAL 00 TOTAL
ire of A ant/ ontraclor Data
OFFICE COPY '