6535 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
:BUILDING PROJECT IDENTI FICATION PERMITNUMBER ,
6DrLDrNG APPLICATION & PERMIT r
/ ADDRess `5
. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL � '
OWNER'S , ;� - - - ®- -- PLAN GREG Is VALIDATION
-� NAM1' C;CDTV. ELECTRIC PERMIT FEE -
' PHONE ••I
rCiame AcroRs UTLETS SWITCHES 'RECEP 5.00/1.00
UC,No., LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S - APPLIANCES-RESIDENTIAL -'4.00
ADDRFSS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT r' t SIGNS 6.00 PLAN CHECK FEEP.C.NO.
OR
FNGINEER ^' "
' - - Lic.No. 'SIGNS TRANS. 3.00
ARCH.OR
ADDRESS E"G. SPECIAL CIRCUIT.• 5,00 PERMIT VALIDATION
ZIP rEMP.METER OR POLVAILJ 15.00 I/�• ,
APPLICANT Sl a J
ADDRESS r MOTORS SEE FE SCH
' SERVICE CHANG 000
'09 ' ' LICENSED CONfRACfORS DECLARATION - •����/
a u w I hereby affirm thab l am licensed under provisimis of Chapter 9 t. . ,• - City0f (;uperlilluISSUANCE DATE
to a H (comniencrng will%Section 7000)of Division 3 of the Business and
BLDG. ELECTPLGMEC
. . . H.
H to r Profession,Cod .and... license is in full farce anti effect p Y f ❑ ❑ ❑ ❑
Z z,m o LicenseClass_ Lie.Number - - -
O m F w Date - Contractor �'' ,d ✓
Y T Z 15^F) �.<►�. �.onir h BUILDI�r,•p9�¢�u•IT
IM 0 W - 'On thin i UILDF pt from RATION I INFOIiMArION
w 3 u H I hereby affirm that I um exempt from Ilio Contractor's License MISC.- REFER TO OR
a. 0 4 Law fon the following reason.(Sec.7031:5•Business and Professions S/FT.
r - g - PERMIT ISSUANCE 6.00 ✓/yA..,1tr 81 19,84
ne Code:Arty e,demyOr county which structure,
permit recosmant.aheq —
ru K G O improve,demolish,or repair any permit
toff prior teits issuance,also ELEC.CONTR. _ '-,LIC NO. IOTA r/i --
0 a- requires the applicant for such permi)to of t a signed statement that '• TOTAL' (� to O
n 6 Jul r j� .y
K
m u he Is licensed pursuant to the provisions of the )ofDivmr's Sof the.
Oupel lino
5zi Law(Chapter s;and9(cosionsCodeng )orthSection
ie7000)ofDivemotol'nd S�
i o.; Business and Professions Code)or otic he is exempt tlmreGum and QTY. PLUMBING PERMIT FEE
+¢ H m lire basis for the alleged exemption.Any violation ol'Section 7031.5 - STORIES TYPE CONSTR,
a3- by any applicant lora permit subjects the applicant toacivil penalty, ALTER-DRAIN -WATER (EA.)drool ncre than five hundred dollars 1$5001.) -
❑ I,as owner of the properly,or my'employees with wages as BACK FLOW PROTECT. DEVICE 2.00 - OCC.GROUP RES.UNITS
their sole compensation,will do the work,anti lire Structure is not
intended or offered for'Vd,.(Sec. 7044, Business and Professions .. DRAINS-FLOOR,ROOF,AR EA,COND. .4.00 .
Code:The Contractor's License Law does not apply 16 an owner of
properly who buildi or improves thereim,and It.dues such..,it FIXTURES-PER TR AP 4.00 SO.FT.FLOORAREA TOTALACREAGE
f himself or through his own employees,provided that such improve. .
mLuts are not intended oroffered forsale.IL I'DWIver,me building GAS-EA.SYSTEM-I1NC.40UTLETS .4.00
or improvement is sold within one year.of completion,the owner-
builder will have the burden of proving that he di A not build or ins- GAS-EA.SYSTEM-'OVER 4(EA.) 1.00 BUILDING USE
tit prove for purpose of sale.). . . , RES No CON PB Other
❑ 1,as owner of the ,,,)Perry,am.exclusively contracting with INDUSTfl IALWASTE INTERS 20.00 O, E ❑ 0 O
licensed contractors to construct tlm project(Sec. 7044,BusinessLAWN SPRINKLERS-1 INC 5 V:B. 5.00 ASSESSORS PARCEL NO.
( and Professions Code:The Contract ar's License Law does 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 contractogs)licensed pursuant to
u
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
. 06 I aur exempt undci Sec. ,B.&P.C.for this
reason. WATER HEATER W/VENT 4.00
Owner=. Date a- r WATERSYSTEM4.00 ACC.OATE ACO,Fdl,E NO.
WORK ItRS'COM ITNSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure. - -
Or a certificate of Workers'Compensation Insurance;or a certified - ZONING ENG.SITE NO.
copy thereof(Sec.3800,lair C.).
Policy No - Company a r.
Q ❑ Certified copy is hereby furnished: FIRESPRINK ENERGY T 24
z'2 .•, ❑ Certified copy is filed with the city inspection division.
'O. Applicant MISC.- REFER TO ORD. v � Nv ❑ NC]
~ N ' ' PERMIT ISSUANCE 6.00 "
'� -�, Cl:RTIPICAI'E UI'IiXBMPI'ION FROM WORKERS',' . � FLOOD ZONE. A.L.u.C.
'W � COMPISNSATION INSURANCE PLG.CONTR, LIC.NO. PLG. .
CL 0" T I is.sectu m need not be completed if.the permit is for one TOTAL Y IN Y [D N0
�.2 hundred doll ars fS100)orlcss,)
•
00 I certify that in the performance of the work for which this per- OTY.. MECHANICAL PERMIT FEE FEE SUMMARY
LL f- mi[is issued,I shall not employ any person in any manner sur as to. ' -
become subject to the Workers'Compensation Laws'of California.
LU Date � Applicant - BUILDING )
} W NOTIC1'-TO APPIACANI'; If,after making Ibis Certificate ,FLT- ALTER OR ADD TO MECH. �4.00 �a(
H ? emption,you Should Become subject to the Workeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the labor Code, you must forlhwitti comply with - FEE 2
• U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,(ID0GF.M.) 3.00
CONS'fRUCfION LENDINGAGENCY. AIR HANDLING UNIT(OVER 10,000C.EM.) 5.06 SEISMIC FEE �-
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. MICROFILM
7097,Civ.C.). . . " HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name` HEATI NG UN IT(OV ER 100,000 B.T.U.17.50 4`TJ
Lentier's Address - ELECTRIC
_ I certify that I have read this application and statethat the above VENTILATION FAN (SINGLE) 3.00
`inforniation.is correct.1 agme to comply,willt all city and county g01LER-COMP(3 H.P.Or 100,000 B.T.U.) 4,00 PLUMBING
ordinances and state laws whining'lo building construction, and
il' r hereby authorize representatives of this city to enter upon the
zbovomentioned property for inspection purposes. BOILER-COMP (Over 100,0000TU)SEE FEE SCH. MECHANICAL
agree to te e, indemnify and keep harmless.the City of MISC.'- 'REFER TO ORD.
Cuperrin against"I bilities,jud• - osts and expenses which PERMIT ISSUANCE 'CONST.TAX
ay in y ova t said Cit in consequence of the
b anti^` . fthispr MECH.CONT., - LIC.NO. MECH.
JQA I?, TOTAL TOTAL 0I 4
Srgnaure Of App I cant/Con I ate1. 1 -
_r OFFICE COPY -