12755 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
gOILDINc APPLICATION & PERMIT
BUILDING -ELECTRICAL-ADDn E55 r, DUAm MECANICAL 12755 CC
H
OWNER'S PLAN CHECK VALIDATION
"AME .
cU OTY. ELECTRIC PERMIT FEE
�\AMSPnoN 5'S (Q0
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
�fl-T7N(-s uc.rvO 04y)o'L LIGHTINGFIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS ``
'7-k LLL:r PHON 670J PANELS 10.00 GATE OF PL ATI
ARCHITECT PANELS (OVER 200 AMP) ZO.OU AN CHECK FE C.NO,
ENGINEER
OR 1
LIC.NO. SIGNS TRANS. 3.00
ARCH ENG. SPECIAL CIRCUIT S.00 ER IT L ATION
An
ZIP EMP.METER OR POLE INS. 20.00 t�I►ry�
ADDRESS MOTORS SEE FEE SCH. [ IVY
ADDRESS
SERVICE CHANGE 20.00 JAN 2 31987
00 LICENSED CONTRACTORS DECLARATION
<u I hereby affirm that 1 am licensed under provisions of Chapter 9 T
m<i% (commencing with Section 7000)of Division 3 of the Business and BLDG.
H O i Professions Codc,and accrue is in full for n dt�'
z o yr License Class U Lic.Number Y / ❑ ❑ ❑
o m w Dafe Contractor
a y s BUILDING PERMIT
a ¢
OWNER-BUILDER DECLARATION INFORMATION
w¢ ooO MISC.- REFER TO ORD
; LL r- I hereby affirm that I am exempt from the Contractor's License
woo Law for the following reason.(Sec.703 1.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION ' $/FT.
� y Code:Any city or county which requires a permit to construct,alter,
C 2< improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a. CLL requires the applicant for such permit to file a signed statement that TOTAL PE IT O
w $w he is licensed pursuant to the provisions of the Contractor's License
F z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢t$ the basis for the alleged exemption.Any violation of5ection 7031.5 STOR S TYPE CONSTR.
d ; _ by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
(heir sole compensation,will do the work,and(he structure is not OCC.GROUP RES.UNITS
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 50,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-I1NC.40UTLETS 6.00
ar improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have(he burden of proving that he did not build or ii, ES 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 SSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds of improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-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 WCC.DATE ACC.FILE NO.
WORK E RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a cerlificule oremosent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec. HO Lab.C.). / _ -
Policy No. 7 " ompapy ALtSJ)!//17L
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T24
Z Z � Certifie1 cop is f d w'th (he ylly inspection division.
O A(>pl'icant ,�I ,Y- .6y�7A/[, MISC.- REFER TO ORD. Y❑ N❑ Y ❑ No
Fy
LU CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
> COMPENSATION
_ COMPf:NSATION INSURANCB PLG.CONTR. LIC.NO. PLG.
O (This section need not be completed if the permit is for one TOTAL V❑ NO
V ❑ NEI
Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
IL H 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.
W Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ N NOTICE TO APPLICANT: if,after making this Certificate of Ex-
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 ITO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.F.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. HEATING UNIT(TO 100,000 B.T.U.) 6.00 MICROFILM
3097,Civ.C.).
Lender's Name H EATI NG UN IT(OV ER 100,000 B.T.U.)9.50 S b' ELECTRIC
Lender's Address
-
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER•COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authurin representatives of this city to enter upon the BOILER-COMP (Over 10(,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 Lino against Hahilities,judgments, costa and expenses which CONST.TAX
may n any way accrue Mat said City in consequence of the PERMIT ISSUANCE 10.00 (e
g nt gof this permit. ,ry p�7 MECH.CONT. LIC,NO. MECyHLys r/)(
QYI.r(i( PP A) l ) [7-l<l / n.� 1 yy n TO /C/ 5v TAL J\U
SI na,rev of A licant ontm to 0 Dale Jxl (-'Taj y--t y-
OFFICE COPY