11515 APPLICANT TO FILL IN INFOR ATION WITHIN RED LINES - USE BALL POINT PEN ONLY
13U LDINGPROJE TIDENTIFIC I E PERMIT NUMBER
aU,L APPLICATION & PERMIT 11515
Ao
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWN PLAN CHECK VALIDATION
e "" QTY. ELECTRIC PERMIT FEE
PHONE
CONTR TORS L OUTLETS-SWITCHES-RECEP 10.0011.00
NAME
' uc.N . _/lo LIGHTING FIXTURES 10.0011.00
co rR ys
APPLIANCES-RESIDENTIAL 4.00
PHON PANELS 10.00' DATE OF APPLICATION
Rclareci PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
O
OR
ENGINEER
LIC.NO SIGNS TRANS. 3.00
PERMIT VALIDATION
ADDR.RESS
AENO CIRCUIT . !�'h1W1.-y
ss 500
ZIP TEMP.METER OR POLE INS. 20.00 Cpl
^p "T MOTORS SEE FEE SCH. -
J
SERVICE CHANGE 20.00 I, e`
0 0 o LICENSED CONTRACTORS DECLARATION 4 ofL iQ'`III
Q U v 1 hereby affml that I am licensed under provisions of Chapl 9 ISSUANCE DATE
h <w (commencing wljll Se tion]000) i Division J f I cWund BLDG. ELELT. PLG. MECH.
H i 1'rofcssions C license is In full fi
Licen. Class Lic.Number ❑ ❑
Q m r� Umc Contractor '
ams BUILDING PERMIT
¢ ¢o OWNS -BUILDER UF.CLARA' ON INFORMATION
X 3 G I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORE
T_
law for the Following reason.(Sec.7031.5,Buainessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
L- -0 Code:Any city or county which requirua permit to construct,etre',
R ¢0 improve,demolish,or repair any structure,prior 10 its RxmUm,,also ELEC.CONTR. LIC.NO. ELEC.
- ss M requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
ww, he is licensed pursuant to the provisions of the Contractor's License
r z a
Law(Chap ter 9(commencing with See tion 7000)of Division 3 of the
s 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H the basis for the alleged exemption.Any violation of Section 7031.5 STO 15 TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not moa than five hundred dollars(S5o0).):
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure Is not OCG GROUP PES.UNITS
Intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code The Contractor's License Low 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 AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsarenolintendedoroffered for sale.If.however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 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 int- RES IND CON PR Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 300
O 1,as owner of the property,am exclusively contracting with .0 ❑ ❑ ❑ ❑ ❑
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 ecwith acomraclogs)licensed pursuant to
License
L
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. _,tl.&BC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACG FILE NO.
'(�'r�'s� P- SA'r1ON DECLARATION WATER TREATING EQUIP. 5.00
larch a off m that h sic o certlricate of consent to self-insure.
or v certificate oC Workers'Compen. lir n Insu an c,or o c rlific ZONING ENG.SITE NO.
copy timm.ffSec.30,Lab.C.).
Policy No. Company
0 ❑ Certified cop crebyf ed FIRE SPRINK ENERGY T-24
Z = ❑ CertifrcJ py Til• h pectio'�s n dl°Is'°n'- MISC.. REFER TO ORD.
O Applicant _ -��� Y ❑ N❑ V ❑ N❑
CCI'RTIPIC EOF EXEMPT ION FROM WORKERS' PERMIT ISSUANCE
C 10.00 FLOOD ZONE A.L.U.C.
L OMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v❑ N❑ Y ❑ N❑
CL Z (This action and not be completed if the permit 1s for one TOTAL
hundred dollars IS 100)or I..)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I• mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of Cxliforner,
Q i Date Appl¢aat ALTER OR ADD TO MECH. 5.00 BUILDING
} H NOTICE TO APPLICANT: If,after making this Certificate of Ex-
♦- ? enlption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1O=C.EM) 6.00 SEISMIC FEE
I hereby affirra that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.0
the performance of the work for which this permit is issued(Sec HEATING UNIT(TO 100,000 B.T.U.) 8. ICROFILM
3097,Civ.C.).
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.)9.5 ELECTRIC
Lender's Addrtss
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-CONE(3 H.P.Or 100,0006.00
L hereby all
atives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL 0
above-my or inspection purposes.
(We) emnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertiili es,judgments, costs and expenses which ST.TAX
inagainst said City in consequence of the PERMIT IS ANCE 1000gra, In ME .CONT. LIC.NO. MECH.� TorAL TOTALgffatu /Contractor Date �lJ
OFFICE COPY