10862APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT I DENTI FICATION
APPLICATION & PERMIT
— ELECTRICAL—PLUMBING —MECHANICAL
PERMIT NUMBER
10862
BUILDING
ADDRE 5
RCE&BUILDING
OWNER'S
'01igm
QTY. - ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
P«orvE
CONTRACTORS
UTLETS-SWITCHES -RECEP 10.00/1.00
uC.NO. e /q
DATE OF APPLICATION
LIGHTING FIXTURES 10.00/1.00
CDNTRADTOR's
CADOR EBBONTRACTOR
�
ONE �"'/'�
APPLIANCES - RESIDENTIAL 4.00
PANELS 10,00
ARCHITECT
OR
ENGINEER
LIC. NO.
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
AARC
DDRESS ENG,
SPECIAL CIRCUIT 5,00
PERMIT v[K11iAJLor�
TEMP. METER OR POLE INS. 20,00
ZIP
f— -
r EB 4 1986
City
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Cudf]an ense is in full fo `• d f c� �1
License Cl ll.-��' H' Lic. Numbe O�
^
of Cupert.{
ino
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
El 0
Date Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand Pro fessions
Code: Any city or county which requires a permit to construct, alter,
BUILDING PERMIT
INFORMATION
MISC. — REFER TO ORD
PERMIT ISSUANCEVALUATION
10.00
$/FT.
ELEC. CONTR. LIG NO. ELEC.
TOTAL
improve, demolish, or repair any Structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
Int is licensed pursuant to the provisions of lire Contractor's License
RMIT TO
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
OTY. PLUMBING PERMIT FEE
the basis for the alleged exempllon. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil pmially
of not more thus five hundred dollars ($500)J:
- STORIES
TYPE CONSTR.
ALTER -DRAIN -WATER IEA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5,00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 5.00
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsarenotintendedurroffered for sale. If, however, the building
SO. FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, lire owner-
builder will have the burden of proving that be did not build or ire.
GAS - EA. SYSTEM - OVER 4 IEA.) 2A0
BUILDING USE
prove for purpose of sale.).
0 I, as owner of lire property, am exclusively contracting with
E IND CON PB ower
O
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contraetons) licensed Pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ [am exempt under Sec.—, BARC. for this
reason
WATER HEATER W/VENT 6.00
Owncr Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WORK ERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate Of con Vnt it) self -Insure,
ZONING
ENG. SITE NO.
or a certificate of Workers' Compensation Insurance, or a certified
copy IreSSQO�Lab.C. L rssl��\
Policy Nt(C-Sr.�S7C7PAdrpany )r -N
❑ Certified copy is hereby furnished.
77��CctliJ_ynp)L is fil[��ey1 flm city inspectiondivision.
A �Plican t r'�l i''i� N-1 TL
FIRE SPRINK
Y� N0
ENERGY T�44
Y0 NE]
MISC.- REFER TO ORD.
CI:R'I'IFICA'1'EOF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10,00
FLOOD ZONE
A.L.U,C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y [J ND
I Y E] N
PLG. CONTR. LIC. NO.
I.G.P
TOTAL
hundred dollars ($100) or less.)
1 certify that in the performance of the work for which this per,
mil is issued, I Shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workeri Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5,00
NOTICE TO APPLICANT: If, after making this Certificate of 1?x-
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
PLAN CHECK
FEE
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.
AIR HANDLING UNIT (OVER 1000C.EM.) 6.00
SEISMIC FEE,
CONSTRUCTION LENDING AGENCY
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.
3097, Civ.C..
MICROFILM
HEATING UNIT(TO100,000 B.T.U.) 8.00
Lender's Name
Lender's Address'
H EATI N G U N IT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
I certify that 1 have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and slate laws relating to building construction, and
PLUMBING
BOILER-COMP13 H.P. or 100,000 B.T.U.1 6.00
hereby authorize representatives of this City to enter upon the
above-mentioned property for inspection purposes.
BOILER -COMP (Over 100,000 BTU) BEE FEES M.
MECHANICAL
(We) ag/Pe to Save, milemnif and keep harmless the City of
noainst liabilities, jud eats, Costs and expenses which
way accrue a in said Ci[N in conseguence of the is permit..
may6
MISC. - RE ER O11
CONST. TAX
PERMIT ISSUANCE 0.
MECH. CONT. LI . NO. MECH.wApplicant/Contract
rf � �t-JzJ I; ror� f
TOTAL
Date-
OFFICEP