3451APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY��-
. BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
I -
BUILDING —`ELECTRICAL— PLUMBING — MECHANICAL
ER M R
3451
BUILDING
aFOR EBB G�y - l -y
O L L G�
OWNER'S
NAME,Z(J
6)
-� - --— --- --- -- -
OTV. ELECTRIC PERMIT FEE
1 1
PLAN CHECK VALIDATION
PHONE
'
- DATE OF APPLICATION
CO TRACT 'S -
N E 2 ¢
'��O••-/ ua No� rJ Q
OUTLETS -SWITCHES - RECEP': 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S
A RES$ y `J•
�0 7 PHONE �+ ,�
APPLIANCES - RESIDENTIAL 4.00
PANELS ' 5.00 -
ARCHITECT - -
OR
ENGINEER
' uc, NO
- .
.SIGNS 6.00
PLAN CHECK FEE P.C. NO.
a SIGNS TRANS. 3.00
AAHCH OR DDRESS ENG
SPECIAL CIRCUIT "5,00
pEflMIT VALIDATION
rrEMP. METER OR POLE INS. 15.00
ZIP
APPUCANrsSS -
ADDRE
MOTORS "SEE FEE SCH:
SERVICE CHANGE•^n 10.00
'.
j Y( o�
ISSUANCE DATE
LICENSED CONTRACTORS DECLARATION
I affirm that -I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect
LCemKCluss Lic.Nomber
Pc olre.( �, •Cp �2 f3
GOY Kd�2 C G (-2
BLDG.
; ❑
ELECT.
El-
PLG. MECH.
❑ ❑
-
Date Contractor
OWNER -BUILDER DECLARATION
- I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031,5, Business and Professions
Code: Any city or county which requiresa permit to construct, alter,
BUILDING PERMIT
i INFORMATION
MISQ.— .REFER TO ORD
ATION $/FT.'
PERMIT ISSUANCE 5,00
I-
ELEC. CONTR. LIC. NO.
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ELEC.
TOTAL
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit t0 file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 - 3
( ptr (fusion, CngwBh Section is exempt
Business and Professions Code) or that he is exempt therefrom and
and
IT TO
l-r�Ad� -
QTY. PLUMBING PERMIT FEF{1
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant fora permit subjects the applicant too civil penally
of not more than five Imndred dollars ($500).1:
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
�a�V
TYPE IN R.
•�' r!l �AOD�
n
ALTER- DRAIN&VENT-WATER (EA.) 4.00
-
BACK F LOW PROTECT. DEVICE 2,00
Occ. GROUP
RES. UNITS'
DRAINS -FLOOR, ROOF, AREA,COND. 4.00 '
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-
mentsare not intended oroffered for sale. If, however, the building
FIXTURES - PER TRAP 4.00 1
GAS- EA: SYSTEM- 11NC. 4 OUTLETS 4.00
SO, FT. FLOOR AREA
•
TOTAL ACREAGE
,
or improvement 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 )'
❑ I, as owner of the property, am exclusively contracting with
GAS - EA.'SVST EM -OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON Pe Other
❑ u ❑ ❑ ❑❑
INDUSTRIAL WASTE' INTER. 20.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon, and who
LAWN SPRINKLERS -I INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
'
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for sueWprojects with a controclons) licensed pursuant to
the Contractor's License. Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ lam exempCunder Sec. ,R'&P.Cforthis
WATER HEATER W/VENT 4.00
reason
Date Owner
WATER SYSTEM 4.00
ACC: DATE
ACC. FILE NO.
WORKERS'COMPE,NSATION DECLARATION
WATER TREATING EQUIP, 4.00
I hereby affirm that 1 have a certificate of consent to svlt imsco,.
of a certificate of Workers' Compensation Insurance, or a certified
_yONING
ENG. SITE NO.
copy thereof (Sec. 3800, LAA.).
"
'
Policy No. Company
'
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.
Applicant
"
FIRE SPRINK-
V ❑ N❑
ENERGY T 24
Y ❑ No
MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT.ISSUANCE 6:00
-FLOOD2o NE.
A.L.U.c.
PLG.CONTR. _ LIC. NO.
PLG."
TOTAL
COMPENSATION INSURANCE
.(This section need not be completed if the permit is for. one
-Y ❑ N❑
Y ❑ INC],
-
hundred dollars IS 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ y person i.. anner xo as to.
bacpy1� wy{� tp.t�iy Workers' n 'anon L nC l ', r'
Da[G—L•�!Yl4pplicant
NOTICE TO APPLICANT: If, after mak' g this rtlficate of Ex-
CITY.MECHANICAL PERMIT. FEE
FEE SUMMARY
'
BUILDING
S'a
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be,deemed revoked.
EEE
"
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
CONSTRUCTION LF,NDINGAGENCY.
AIR HANDLING UNIT IOVERA0=C.F.M.)5.00.
SEISMIC FEE
1P
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued (Sec.
3097, Ci,,C.). -
MICROFILM
'HEATING UNIT(TO 100,000 B.T.U.), 4.00
HEATING UNIT -(OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
1 certify that I have read this application and state that the above
VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
'PLUMBING
BOILER- COMP (3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city .to enter upon the
above-mentioned property for inspection purposes.
MISC. = - 'REFER TO ORD.
-
CONST, TAX
(We) agree to save, indemnify and keep hsnnless the City of
Cuper.ino against liabilities, judgments, costs and expenses which
may i any way accrue -against said City in consequence of the
PERMIT ISSUANCE - 3.00
gran' go this;permi[.
MECH. CONT. LIC NO,
dlw- L
I'
LMECH,22
TOTAL
Signature of Ap ¢ant/Cont actor Date
OFFICE COPY '