4713APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATIONPERMITNUMBER
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
' • 4 713
Bu,LD,Nc
aooRE s
l� O 'I "1
OWNER'S 4047
NAME Y
LQ ONE
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
NEMER"croRs
NOE E C. NO. JD
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
rouTRACT ADDRESS 415' ryIs
PNONE l
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
AARRCH;TECT
ENGINEER
LIC. No.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ADDRESS ENG.
ZIP
SPECIAL CIRCUIT 5.OD
PERMIT VALIDATION
ISSUANCE DATE
TEMP. METER OR POLE•INS. 15.00
APPLICANTS
ADDDRESSDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions CoJe.Atndpy license is in full force aFdlf('
License ass ((.� 77 �-11 Lic. Numher_AJ Qt./
Dale_ Contract
OWNER -BUILDER DECLAR 'ION
I hereby affirm that I so exempt from the Contractor's License
Law for the following reason. (Sec. 703 t.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter.
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit IO file a signed Statement that
he is licensed pursuant to the provisions of Ilia Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of t he
Business and Professions Code) or that he is exempt therefrom and
the basis for file alleged exemption, Any violation of Scction 7031.5TYPE
by any applicant for a permit subjects thapplicant loa civil penalty
of not more than five bmsdred dollars (8500).):
❑ 1, as owner 01 the Property, or niy employees with wages as
their sole compensation, will do ilia work, and the Structure is not
intended or offend for sale (Sec. 7044, Business and P,olesaiotis
Code: The Contractor's License Law does not apply to an owner of
pinperty who builds or improve, thereon, and who dues Such work
himself or through his own anpBoyces. Provided that such ireProve-
ments are not Intended proffered for sale. If, however, the budding
or inpravantent is sold whiiin one year of completion, theowner-
builder will have ilia burden of prnving that Ire did not build OF ire-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
licensed cm ametors to construct the projuat (Sec. 7044, Business
and Professions Coda: The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon. and who
contracts forsuch Projects with a contractions) licensed pur,um;t IF,
the Commhm-'s License Law.
reason ❑ I am exempt under Sec. ,BARC. for this
T F•
(A+ 9 /
BL G. ELECT,
❑
I PLG. FOR,
❑ ❑
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
op
J /tide TION
/
$/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. N0.
-
ELEC.
TOTAL
ny.a.r� TO
(Ifl�fri('JY
QO R.e-T
QTY. PLUMBING PERMIT FEE
ite
Y�jn
CONSTR.
h(,"/r_CS
ALTER -DRAIN -WATER (EA.) 4.00
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
-
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, GOND. 4.00
FIXTURES - PER TRAP 4.00
so. PT PLoon AREA
roraL ACREAGE
GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
. ..
GAS - EASYSTEM -OVER 4 (EA) 100
BUILDING USE
RES IND CON PB Omer
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
ASSESSORS 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
Dace Owner
WORK ERS'COMPENSAT'ION DECIARAT1ON
1 hereby affirm that I have a certificate mf consent m sell -insure,
or a certificate of Workers' Compensation Insurance, or a certified
copy IherenffSec. 3600, Lab C.).
Policy No. Company
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.MISC.
Applicant
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO,
WATER TREATING EQUIP. 4.00
ZONING
ENG. SITE N0.
FIRE SPRINK
Yo N[3
ENERGY T-24
V E] N[j
- REFER TO ORD.
C1:RT[FICATI:017 ]1X[:?1PTION I�ROM WORKI:RS•
COMPENSATION INSURANCE
(This section need not he completed if the fiction is for ane
hundrer] dollars IS 1000 or less.)
Diwork It,, which this per-
I certify that in the per IF �,ypep"2'ti
mit is issued, I shall not emon in ; ny manner v as to
become sub' act to the WorkI , ws of dilernyyqqDatc.<D-Apel: eay.
A PLICAN' lirg s ani ae o x-
emptimn, you should become subject t the workers' Coni pensa tell
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
CONS1'RUC'I'1ON 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.
3097, Civ.C.). -
Lender's Name'
PERMIT ISSUANCE 6.00FLOOD
ZONE
Y ❑ N
A.L. u. C.
y E] N
PLG. CONTR. LIC. NO.
PLG.
TOTAL
CITY MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
.S"�NOT
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10MCF.M.) 3.00
AIR HANDLING UNIT (OVER 10,000C.FM.) 5.00
SEISMIC FEE
4-0
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
H EATI N G U N IT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Address
I certify that I have read this application and state that the above
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating in building CORSIRIC11011, and
hereby authorirc representatives of this city 4s enter, upon the
above-mentioned property for inspection purposes,
(We) agree to salla indmnmify un I keep Irani less the City of
CuperY to against liabilities, Judgments, costs and expanses which
may any way accrue against said City in consequence of Dm
gra of this permit.MECH.
a are of pelican milructor Uatc
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER- COMP (3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTUf SEE FEE SCH.
MECHANICAL
MISC.- REFER TO ORD.
'
CONST. TAX
PERMIT ISSUANCE 3.00
CONT. LIC. N0.
MECH,.
TOTAL
TOTAL
00
OFFICE COPY