9267 APPLICANT TO FILL IN INFORMATION RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATI CA& I PERMIT NUMBER
BILGING ` 5 APPLICATION & PERM
40 sIs D O� / UILDING-ELECTRICAL-PLUMBING-MECHANICAL 9267
O NER' / 7/L PLAN CHECK VALIDATION
NAMEAar DTV. ELECTRIC PERMIT FEE
•
PHONE
coNrSAc]oH OUTLETS-SWITCHES-RECEP 10.00/1.00
E
uC.N LIGHTING FIXTURES 10.00/1.00
r, TRACTOR'S APPLIANCES 4.00
D Ess
llfAI Il PHONE PANELS Ei
10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
I.C.No, SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.0 P IDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH. AJU� 1
ADDRESS
SERVICE CHANGE 20.00 um of CUP0141
D o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
ID u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DOCTEA
w Q w (co..unending with Section 7000)of Division 3 of the Business and BLDG. ELECT. MECH.
E.w z Professions Cod !�9�ce Ilse is in full fore � ❑
z o m- License Class_V 0 Lid.Nroli _ ❑ ❑
o w H Date Comruclor
P y s wt
BUILDIN PERMIT
¢ w OWNER-BUILDER DECLARATION
0 MISC.- REFER TO ORD INFO ATION
w3 LL N 1 hereby affirm that I um exempt from the Contractor's License VALUATION $/FT.
H .. o¢ Law for circ following reason.(Sec.]031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which Politics permit toconstruct,alter,
Q Q Q improve,demolish,Or repair tiny structure,prior to Its Issuance,also ELEC.CONTE. LIC.NO.
ELEC.
O ¢ requires the applicant for such permit to file a signed statement that TOTAL P rytlT TO
n w m" he is licensed pursuant to the provisions of the Contractor's License
r z r
Law(Chapter 9(commencing with Suction 7000)of Division 3 ofthe
¢ Rosiness and Professions Code)or that hu is exempt therefrom anJOTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of$ection 703 L$ STO ES VPE CONSTR.
dam by any applicant for a permit subjects lire applicant toacivil penaltyALTER=DRAIN& VENT-WATER IEA.) 5.00
of not more than five hundred dollars(S500).):
❑ 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,AR EA,COND. 5.00
Code:The Contractor's License Law docs 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 AHEA TOTALACREAGE
• himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
meats are not intended or offered I'or sale.If,however,the building
ur improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
no de,will have Ole burden of proving That he did not build or int- IND CON PB Orher
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑
IicenuJ contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for Such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor s License Law. '
❑ 1 not exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAT'ION DECLARATION WATER TREATING EOUIP. 5.00
I hereby Infirm that I have it certificate of consent to sell-insure. ZONING ENG.SITE NO.
or a ccrtificule of Workers'Compmtsution Insurance,or a certifiedA
copy thcrcofl Scc.3800,Lub.0
Policy No. Cor to
❑ hcd y r umished. FIRE SPRINK ENERGY T-24
Z Z Certirie - yjll( !)v inspection tlivision. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
O A plica nl /I�� Y N V N
c N CERT'I IFICATE 01'Ii%EM PITON PROM WORKERS' PERMIT ISSUANCE 10.0FLOOD ZONE A.L.U.C.
L � COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. / 7fJ yl
N❑ v❑ NEI
CL ❑ TIES section need not be completed if the permit is for one TOTAL C(G�J
D Z hundred dollars(8100)of less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
U beL<nne subject w the Workers'Compensation Law,of Culifern iu.
w Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
ED NOTICE TO APPLICANT. If,after making this Certificate of F,x-
F.. ? toniumn,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 10,000C.F.M,) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOAODCEM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work far whish this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lenders Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• infornmtion is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating m building construction, and BOILER-COMM H.P.or 100,000 B.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 lin inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupc,ino%-g.ml.bflj�cs,judgments, costs and expenses which CONST.TAX
may - aagri said City in consequ ce of the PERMIT ISSUANCE 10.00gr in MECH.CONT. LIC.NO. MECH.
l2STOTAL TOTAL
ignator ntractor ate
OFFICE COPY
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