12109 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BGILOING APPLICATION & PERMIT 12109
AOORESs
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
"AME QTY. ELECTRIC PERMIT FEE
PHONE
DOrvTRpcTOR$ UTLETS-SWITCHES-RECEP 10.00/1.00
N^AME
\-�`- LIC.No LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDREss
PHONE PANELS 16.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.06 PLAN CHECK FEE P.G.NO.
On
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH,OR ENG. 5.00 PERMIT VALIDATION
ADDRESS
SPECIAL CIRCUIT
zap FEMP.METER OR POLE INS. 20.00 � ~ ��'�p
ADDRESrvr's MOTORS SEE FEE SCH. �J
ADDRESS `i1/`
SERVICE CHANGE 20.00 N /
'02
LICENSED CONTRACTORS DECLARATION lilt _U T
SE in U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z Professions Cod .ymt license is in full fur d c f C{,n E] ❑ ❑
Z
o m License lass Lic.Numbe 1 _
rvq
0 z F w Date Contractor
F " Vy-
BUILDING PERMIT
w¢ OWNER-BUILDER DECLARATION INFORMATION
OaD MISC.- REFER TO ORD
wS LL w I hereby affirm that I am exempt from the Contractor's License VALUATION $TFT.
HLNa Law for the following reason.(Sec.703L5.Business and Professions PERMIT ISSUANCE 10.00
wCode:Any city orcounty which requires a permit to construct,all er,
a improve,demolish,or repair any stnahrC,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT T
a O
w m he is licensed pursuant to tire ��i-
e provisions of the Contractor's License ,j
ol z a
Law(Chapter 9(commencing with Section 7000)of Division3of PLUMBING PERMIT FEE
the
E i D Business and Professions Code)or that he is exennpt therefrom and QTY.
H$ the basis for the alleged exemption.Any violation of Secliun 7031.5 STORIES TYPE CONSTR.
Ate' of noimorelicant forfivhuWrn Subjects(heap applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sell,compensation,will do the work,and the structure is not
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 FIXTURES-PER TRAP 5.00 So.FT ELOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
( mems are not intended or offered for sale.If,however,lire building
or improvement is sold within one year of completion,tine owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have lire burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as.wall.1 the property,am cxclusivcly contracting with
IicenseJ 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 docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a Cnn mClOns)licensed pursuant to
octor's License Law. SEWER-SANITARY-STORM EA.2 Oft/10.00 TRACT NO. PARCEL No.
the Cntra
❑ l..exempt under Sec..,B&P C.for this WATER HEAT /VEITf V 6.00
reason
Owner Date WATER SYSTE 5.60 ACGpATE ACC.FILE NO.
WORK ERS'COMPENSA'I'ION DIiCLARATION WATER TREATINt EQUIP. 0
1 hereby affirm (hat 1 have a certlhcate Ere....scm to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thefTt!�o��,,�LS,,,e,yy-���� 0.Lsb.0 1 1\ _ m �1.1�
PolicyN91.6 litany \�'� FAFl
Q ❑ Certified copy hs her by furnished. FIRE SPRINK ENERGY T-24
Z_ Z Ort Cerl is 'Uhl Hhe city inspection division. MISC.- REFER TO ORD. YE] NF' YE] N0
A Ali Cee A la
♦- y PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
- CERTIFICATE 01'EXEMPTION FROM WORKERS'
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. YEl NR YEl N1:1
CL O (This section need not be completed if the permit is for one TOTAL
dD Z hundred dollars IS 100)or le,)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,I slhall not employ any person in any manner m as to
O w become subject to the Workers'Compensation Laws of California.
nate Applicant ALTER OR ADD TO MECH. As`la 5.00 BUILDING
} to NOTICE TO APPLICANT: If,alter making this Certificate of li x- ,
F 2 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(TO 10-=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 100W .EMJ 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
3097,Civ.CJ. B.T.U.) 8.00 MICROFILM
Lenders Name HEATI NG UN IT(OV E R 100,000 B.T.U.)9.50 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 BOILER-COMPO H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stmt laws relating to building construction, and
hereby authorize representatives ins el, this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
abovrml,mionCJ property I'or inspection purposes.
Af
(We) agree to save, indemnify and keep harmless tine City of MISC.- REFER TO ORD.
Cape ino against liabilities,judgments, costs and expenacs which PERMIT ISSUANCE 10.00 �Q CONST.TAX
may i any way gcem ag Inst said City in consequence of the
g nti g of this permit. MECH.CONT. LIC.NO. MECH}.�1,
6 u i°! V TOTAL
Si6nature of Applicant/(Omract TA
Date1A 19 �G04
OFFICE COPY