6281APPLICANT TO FILL IN INFORMATION WITHIN RED LINES''- USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
to A NO
ADNEax
`iC U jZTt n C V34 -
.Ne. A
NAME L_mp
PHONE
CONTRACTOR'S
NAME J � 1L-• PGli1l \FJIx
f • uc. Nn.
CONTRACTOR'S I'� �J
ADD .FEES 1 'J 1 /o cDehi .rl/LTI„ION f/./y'y'yll
bl e C 1 PNONE I O�
OR
ENGINEER ��-
LIC. NO.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
'commencing with Suction 7000) of Division 3 of the Business and
Professions Cod• nd qq��KK license is in full fore
License Cls C; � 5L_Lie..is Number_ Ci
Datc_.7.L'j__.�V^ Contract.,
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License
Law for the following reason. (Sec. 703 1.5, Businessand Professions
Code: Any city or county which requiresa permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000)bf Division 3 of th
Business and Professions Code) or,that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant tox civil penalty
of not more than five hundred dollars ($500).):
❑ I, as owner of the property, or my employees with wages as
their sale compensation, will do the work, and the structure is not
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 thereon, and who does such work
himself or through his own employees, provided that such improve.
meets are not intended or offered for sale. If, however, the building
orimprovement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
contmets,for such projects with.a conlractons) licensed pursuant to
the Contractors License Law.
❑ 1 am exempt under Sec. , BAP.C. for this
reason
Owner Date
WORKERS'COMPENSATION DECLARATION -
1 hereby air nn that I have a certificate of cmhsent ro self -insure,
or a certificate of Worke s' C pensaton Insurance, or a certified
copYtherepff 5'eg�dRO r`10upan /y�-![\A,
Policy e' .Sl Clfmpany-.Ff INIJ li K
❑Ceth ied copy is hereby furnished.
T}•Certi fiedLcSl+yh Jl.f kd syj(h t y etion division.
Alff licanl_ P-tiKi��i3-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars (5100) Or less.)
I certify that in the performance of the work for -which this per
mit is issued, 1 shall not employ any person in any manner so as IT
become subject to the Workers' Compensation Laws of California.
Date -'Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex
emption, you should berome subject to the Workers' Compensat for
provisions of the Labor Code, you must forthwith comply will
such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm diol there is a construction lending agency to
Iheperformance of the work for which this permit is issued (Sec
3097, Civ.0.).
Lender's Name
Lender's Address
I certify that 1 have read this application and state that the abon
information is correct. I agree to comply with all city and count!
ordinances and stale laws relating to building construction, am
hereby authorize representatives of this city to enter upon the
above-mentioned property forinspection p poses.
(We) ee to save, indemnify and k harmless the City o
Cuperlin against lities, jud mens, sts and expenses whicl
may in y way ue again said in consequence'of IN
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
^ ^
bG 81
f} I� A a.aNv a NS r''�x`
OTV. 4•ELfECTRIC,�P�,E4RMITw�:1'^•I' FEE
PLAN CHECK VALIDATION
-
DATE OF APPLICATION
.� UTLETS- SWITCHES -RECEP 5.00/1.00
Z LIGHTING FIXTURES 5.00/1.00
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
SIGNS 6.00
PLAN CHECK FEE P.C. No.
SIGNS TRANS. 3.00
SPECIAL CIRCUIT - '5.00
PERMIT VALIDATION
n /
ISSUANCE DATE
EMP. METER OR POLE INS. 15.00
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
PAW
BLDG,
❑
ELECT. I PLG.. MECH.
❑ ❑
f CiUpe�t�0'
•'= - BUILDINGPE IMIT-
'x FORMAIT10N
MISC.- REFERTOORD -
VALUATION
PERMITTO
PERMIT ISSUANCE Asx _
ELEC. CONTR. LIC. NO.
ELEC, r��x ��ra ] (V
TOTAL p -v3-
OTV�,'� x -( PLUMBING' PERMITS 1,,. =a�FE&
e;n' : I'. ,
STORIES
TYPE CONSTR.
'
ALTER -DRAIN & VENT -WATER (EA.) 4.00
BACK FLOW PROTECT. DEVICE' 2.00 -
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,CONO.'4.00
FIXTURES - PER TRAP - 4.00
60. FT. FLOOR AREA
TOTAL ACREAGE
'
GAS. EA. SYSTEM -1 INC.4 OUTLETS 4.00
GAS - EA. SYSTEM - OVER 4 (EA.), 1.00
BUILDING USE
RES I❑ ❑ND . CON PB E] ❑ 0 E],
❑
INDUSTRIAL WASTE INTER. 20.01)
LAWN SPRINKLERS -1INC 5 V.B. 5.00
Asslessoas PARCEL NO.
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA: 200ft/8.00
TRACT NO.
PARCEL NO,
WATER HEATER W/VENT 4.00
WATER SYSTEM ' 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
ZONING
ENG. SITE NO.
't- -
FIRESPRINK
"v❑' N❑
ENERGY T-24
Y❑ N❑
MISC.- REFER TO ORD.
PERMIT ISSUANCE _. 6.00
FLOOD ZONE
Y ❑ N ❑
A.L.U.C.
V ❑ N ❑
PLG. CONTR. '.LIC NO.
PLG.
TOTAL
QTY,.;'. -MECHANICAL PERMIT "'FEE
"',FEErSUMIYIARV 'F
n w
BUILDING
ALTER OR ADD TO MECH. 4:00
APPLIANCE 4:00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10SMC.F.NL) 3.00
AIR HANDLING UNIT (OVER 1000QFM.) 5.00 -
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT.(OVER 100,000B.T.U.17.50
ELECTRIC
0t 0,3
• VENTILATION' FAN (SINGLE) 3.00
PLUMBING -
I .,. BOILER- COMP (3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
•MECHANICAL
f MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3,00
MECH.CONT. LIC. NO. MECH.
TOTAL TOTAL'r?
OFFICECOPY