9313 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT(FICATION PERMIT NUMBER
-71 BD„DING, sp11b APPLICATION & PERMIT 9 313
AooREss
'Tp 7&3tj kWAA)f-LA�Q� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
xv NAM9 CITY. ELECTRIC PERMIT FEE
PHONE
CONTRACTOR
NAME _ UTLETS-SWITCHES-RECEP 1&00/1.00
NOME
C4V- COAST CaaV`�1 0 .tio. G I y LIGHTING FIXTURES 10.00/1.00
COITRACTOR' ..rri�p� ) APPLIANCES-RESIDENTIAL 4.00
ADDRESS .'^, �,eMAAJ vW-- '
M �� W"PHONEtO'� ' PANELS - 10.00 DATE OF APPLICATION
.FCHIT9 PANELS (OVER 200 AMP) 20.00 - PLAN CHECK FEE P.C.NO.
OR
ENGINEER ,L � �_ -
,w uc.NO SIGNS TRANS. 3.00
ARCH.OR ENG. ��� SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS
A - MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00oo TEMPPOLE 30 �� -7
' LICENSED CONTRACTORS DECLARATION . 0
a u I hereby affirm that I no licensed under provisions of Chapter 9 FAIDD/ I ISSUANCE DATE
N Q w (commencing will,Section 7000)of Diviai.p 3.f the Business and �� �� BLDG. ELECT. PLG. MECH.
o Prole cions Code,and my license is in full force and effe�'c-�t'�y',�)' � e�'V�
z D a C, License Cl.' I Lic.Numbe4a ❑ ❑
F H 0
X-
Date- 1Contractor O'��
m ¢< ONIi R-BUILUIiR DECLARATION O BUILDING P,ERMIT�6s "
- o W'a U - MISC.- K R TO ORD
u INFORMATION
I hereby ullinn that 1 am exempt from Hm C.ntracmr's LiconsC - VALUATION
H I. o j Law for the following reason:(Sec.7031.5,Buxiness anJ Professions . PERMIT ISSUANCE �f3e00
Code:Any city or county which requires a permit to construct,alter.
CS
< p improve•demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. q W
iL o u requires the applicant for such permit to file a signed statement that TO,A10.rs PERMIT TO /
u w Cr he is licensed pursuant to the provisions of(lie Contractor's License - /dL.BU-
H z a
Law(Chapter 9(commencing will,Section 7000)of Division'3 of the
E i D
Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
f the basis forapplicant
the allegedexemption,cube Any violation.(Section malty STORIES TYPE CON$TR,
w. F_ by any more
(ora permit dollar,(he0).):ant toacivilpenalty ALTER-DRAIN -WATER (EA.) 5.00
of nut more than five hundred Dollars(5500).1: '
❑ Las owner of the property,or my mnPloyees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sea 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Codv:The Contractor's License Law does riot apply to an owner of
property who builds or improves(hereon,and who does such work FIXTURES-PER TRAP - SO.PT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
cents are not intended or offered for sale.Il',however,the building GAS-EA.SYSTEM-1 INC.40UTLETS 6.00 '
or improvement is Sold within one year of completion,the owner-
` �O builder will have the burden of proving that he did not build or am. GAS-EA.SYSTEM:OVER 4(EA.) 2.00 BUILDING USE
Prove for purport ofsale.L INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pa Other❑ I,as owner of the.property,am exclusively'contracting with ❑ ❑ ❑ ❑ ❑
(( licensed contractors tD construct the project(Sec.7044,Business LAWN SPRINKLERS- 1'INC 5 V.B. '6.00 ASSESSORS PARCEL NO.
q and Professions Code:The Contractor's License Law does not apply
fA to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with it contruchons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL No.
the Contractor's License Law.
❑ I am exempt under Sec. BAP.C.for this WATER HEATER 6.00
reason
V Owner Date WATER SYSTEM 5.00
p ACC.DATE, ACC.FILE NO.
3 WORK FRS'COMPENSA'rION DECLARATION WATER TREATIVP UIP. 98 5.00
1 hereby affirm that I have a certificate of consent t.self-insure, T�.�'� ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
c py thereof(Sce.3800,Lab.C.)' a I AUTJT Cue Ino
olicy No. Company-.12GQ - '
Q MY Certified e.py is hereby furnrshed. - /�' �IAtiL IRE SPRINK ENERGY T 24
Z ❑ CeniGei copN u file) wish the city inspection Division. MISC.- REFER TOO D.
O AppliCanl f J`_ 1_•Q � T a V❑ N❑ Y ❑ N❑
CERTIPICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE FLOOD ZONE A.L.U.C.
COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. / Y❑ N❑ Y ❑ NEI
section need not be completed if thfoO
CL 0e permit is r One TOTAL
Z hundred dollars IS 100)orless.)
U O 1 certify that in the performance of the work for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY• -
LL 1- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers Compvuution laws of CuliI.rma.
ICU
Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certil'iemC-of Ex-
F ? Coalition,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 rCs.kCd. AIR HANDLING UNIT(TO JOSMCF.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that (here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.j. - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's M...c HEATING UNIT(OVER 100,000 B.T.U.)9.50 C/o
Lender's Adan" ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n correct 1 agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws relating c to building lcityand cconstruction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ubovontentioned property for inspection purposes.
gree -ve, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Chino against ilities,judgments, costs and expenses which CONST.TAX
Sy
in y way a rue again said City in consequence of the PERMIT ISSUANCE 10.00
alting f this p IL MECH.CONT. LIC.N0. MECH. T'
Si a re orA plicmaiContract. ate
1�$ OTAL TOTAL O
OFFICE COPY