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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDI NG PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
11034
BUILDING
AD°REB=
'
NER'
AME
PHONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VA1,10I
DATE OF APPLICATION
CONTRACTORS
ME
LIc.
OUTLETS - SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
C rvTR CTORs
A DR 5
APPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
A ITS
O
E GIN
G.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS.3.00
ARCH. OR ENG,
ADDRESS
ZIP
SPECIAL CIRCUIT I® OO
PERMIT VALIDATION
i� �IA
TEMP. METER OR POLE INS. 20.00
APPLICANTS
ADDRESS
MOTORSE¢O . 'S
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
lu ern1
hereby affirm that I am licensed under provisions OfChapter 9
(commencing with Section 7000) of Division 3 of the Business and
INCE DATE
BLDG. E E T. PLG. MECH.
Professions Code d my license is in full force and effect.
UCCA ss L,c. NUnbf,r
Data Contract N
❑ ❑
BUILDI G PERMIT
OWNFR-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand Professions
INFOR ATION
MISC. - REFER TO ORD
VALUATION S/FT.
PERMIT ISSUANCE 10.00
Code: Any city or county which requirese permit mconstructalter,
improve, demolish, Or repair any prior its issuance,
ELEC. CONTR. LIC. NQ
ELEC.
rtractate, talsohat
fell for such permO to file a signed statement that
TOTAL
PERMIT TO
Cont
he is licensed pursuant en the provisions of the Contractor's License
is licenedp ursua
of Division 3 of the
Law (Chapter 9 (co sins Cod ) or Section is exempt
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.$
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (S500).):
1
l
QTY. PLUMBING PERMIT FEE
5
TYPE CONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
❑ I, as owner Of the property, or my employees with wages as
their sole 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 dues not apply to an owner of
properly who builds or improves thereon, and who does such work
himself' or through his own employees, provided that such improvo
mems arc not intended or offered for sale. If, however, the building
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES - PER TRAP 5.00
50. FT. FLOOR AREA
TOTAL ACREAGE
GAS. EA.SYSTEM-I INC.4 OUTLET b 6.00
or improvement is sold within one year of completion, Orn owner
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
U 1, as owner of the property, am exclusively contracting will,
licensed contractors to construct the project (Sec. 7044, Business
GAS- EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND O PR Omar
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSOR PARCEL NO.
and Professions Code: rhe Contractor's License Law docs not apply
t0 an owner Of property who builds or improves (hereon, and who
contracts for such projects with a contractorfs) licensed pursuant t0
the Coinfactor's License Law.
❑ 1 am exempt under Sec.-, B &P C. for this
LAWN SPRINKLERS -OVER 5 IEA.1 1.00
SEWER -SANITARY -STORM EA. 200tt/10.00--TRACT
'NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
reas011
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WORKERS'COMPENSA"PION DECLARATION
WATER TREATING EQUIP. 5.00
I hereby affirm that I have u serf idle 'co est rtryanuc,
o cerlifhcate of Workers' Come 11 bb��'' II'am
ZONING
ENG. SITE NO.
copy thereof (Sea 3800, Lah.C.J, i
Policy No. Compan
❑ Certified copy is hereby lIrUshed.
❑ Certified copy is filed with the city inspection division.
Applicani
FIRE SPRINK
YE] N ❑
ENERGY T 24
Y [:] NEI
MISC. - REFER TO ORD.
CERTIFICATE OF EXFMPP[ON FROM WORKERS'
COMPIiNSATION INSURANCE:
(This action need not be completed if the permit is for one
PERMIT ISSUANCE 10.00
FLOODZONE
YE] N❑
A.L.U.C.
Y❑ N❑
PLG. CONTR.TOTAL LIC. NO.
PLG.
Q'fV MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars ($ 100) or less.I
I certify that in the performance of the work for which this per
mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Daw APPIICam
NOTICE TO APPLICANT: If, after nm king this Certificate of fix-
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.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
Lender's Name
BUILDING
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=r-F.M.) 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
'
VENTILATION FAN (SINGLE) 4.00
ELECTRIC
Lender's Address
I certify that I have raid this application and state that the above
information is correct. I agree to comply with all city and county
ordinances an state Inws relUing to building construction, atilt
hereby autho' represnntmives of (his city to enter upon the
PLUMBING
BOILER -COMP 13 N.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000BTU) SEE FEESCH.
MECHANICAL
abuve-mention property forinspccdon purposes.
(We) agree save, indemnify and keep harmless the City of
Cu *pP.P 'obit:,: dgmenls, costs and expenses which
By Igai t said City in consequence Of the
gr estie il.
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO. MEETAHLTOTAL$i
la reanf/ Nractor IDate
�� OFFICE COPY /