09975 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY .
BU LD1 NG PROJECT I DENTI FICATI ON - - PERMIT NUMBER
BUILDING
. APPLICATION & PERMIT
A
D
DRESS
le L. S pp4te WLDING-ELECTRICAL-PLUMBING-MECHANICAL 09975
'
OWNER'S - PLAN CHECK VALIDATION
NAME TY. ELECTRIC PE�,2 FEE
'.1 CONn
NA cTDR's ( / OUTLETS-SWITCHES•RECEP 10.00/1.00
_ '
50"LIP01
y 4�
' LIGHTING FIXTURES 10.001
CONTRACTORS `DW'OO e APPLIANCES-RESIDENTIAL 4..000a 0
'
^
PRON PANELS • 10.00 DATE OF APPLICATION
ORRcflrtl[cT PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE. P.C.No.
ENGINEER
ue.NO. SIGNS TRANS. 3.00
s. ADDRESS ErvG. , SPECIALCIRCUIT S.QQ PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS rs - MOTORS EE FEE SCH.
S ERVICE,CHANGE PAId '20.00
o o LICBNSIiD CON'TRAC'TORS UBCLAItAT10N TEMP.POLE e ' CP 30,00 -
la i w hereby"affirm that 1 am licensed model provisions of Chapter'I S �' ISSUANCE GATE
a n (commencing with'Semion 70001 of Division 3 of the Business and
SOW,"' BLDG. ELECT. PLG. MECH.
Prolrssions Code, J ou/Ocense is in full'forc 4.- ,
Z, i m G License CI' s_ YV Lie.Number ' �O &P,
y5 Date
G1I Cmuractor _ s"•�V�
+ tilly
a y'E Q�/ ,' I �� - BUILDING PERMIT
rt m a QWNIi R-d UILUhR DIiCL R TIO
IS a v INFORMATION
P.
;,� 1 hereby aff or that I am exempt from the Contractor's License MISC.- REFER TO ORD
F u o 4 Law for the following reason.(See.7031.5,Business and Professions
PERMIT ISSUANCE 10.00 Q VALUATION SIFT.
to Code:Any city nr county which renoi rs u permit to construct,alcq
a o improve,demolish,Or repair any structure,prior to its issuance,also E .CONTR. ELEC. ll 9 fel
a G LL realmires the applicant for such permit to file s signed statement that VJ PERMIT TO
.w he is licensed purmmot to the provisions of the Contractor's License r�
rii
Law(Chapter 9(commencing with Section 7000)of-Division 3 of lire C
a Business and Professions Code)or that he isexempt therefrom and OTV. PLUMB413 PERMIT .FEE
.
acH$ the basis for the alleged exemption.Any violation of Section]071.5 i STORIES TYPE CONSTR.
,.a3 _ by any applicant for it permit subjects the applicant to a civil penalty - gLTER-DRAIN&VENT-WATER IEA.) 5.00
of not mare than five hundred dollars(S500).):
❑ 1,as owner of the property.Or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not ,
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP ,5.00 so.FT.FLOOR AREA TOTAL ACREAGE
himself or though his own employers,Provided that such ibProve-
orimprovemenrrtendcdwithinoffered
onafor sale.
year
If,howeveq the the o nee- GAS-EA.SVSTEM-11 6.00
Dr improvement is sold within one year ha he pint ion,the o r im-
builder will have the burden of proving that he Aid not build or im- iGAS-EA.SYSTEM-OVER 4 (EA:) 2.00 BUILDING USE
prove for purpose ofsale.). ' . . INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pa Other
❑ 1,as owner of the property,am exclusively contracting will ❑ ❑ ❑ ❑ ❑ '
licensed contractors to construct the project(Sec. 7044;Business • LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code: The Contractnh License Law docs 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 contractons)IICBOSed pur5nant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
, .s ❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00 '
reason
Owns, 'rd��r� )at.e�,(.� WATER SYSTEM 5.00 - ACC.DATE ACC.FILE NO.
• Q4q4KC :RST'IjTILI� WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure.
or it certificate of Workers'Compensation Insurance,or a certified I ZONING ENG.SITE NO.
copy thereof(Sec. Lab.CJ. -
Policy ele CCoom pang_ - -
O ❑ Certified copy is hereby torah•d. FIRE SPRINK ENERGY T-24
Z 2 cCn"ifi d with he ity inspection division. MISC.- REFER TO ORD. v N v N
❑ ❑ ❑ ❑
I= O_ PERMIT.ISSUANCE 10.00
LU CIiRTI PICCOM SAX 1 p N FROM WOItKF,RS' FLOOD zorvE A.L.u.C.
W COMI'RNSATIO INSURANCE•t PLG:CONTR. LIC.NO, PLG. `
CL Z ('This section used not be completed if the permit is for one TOTAL V❑ N❑ V ❑ N❑
hundred dollars(E 100)or less)
If) O I certify that in the performance of the work for which this per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I shall not employ any person in any manner so as to
O U become subject to the Workers'Compensation Laws of California. ,
St. Duty Applicant BUILDING
} W NOTICE TO APPLICANT: If,after;making this Certificate'of lix- ALTER.OR ADD TO MECH. 5.00
� Z emption,you should became 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 revoked, 'AIR HANDLING UNIT(TO 10=17.F.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 6.00 SEISMIC,FEE
I hereby afford that them is a construction leading agency for EXHAUST HOOD(WITH DUCT) 5.00
'the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.). `'� �Jr HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name - /V /r�C HEATING UNIT(OVER 100,0008.T.U.)9.50 d 3
Lender's Address ELECTRIC
I certify that I have read this application'and state that the above VENTILATION FAN (SINGLE) 4,00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building•construction, and' BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. ,
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD,
'
Cupara in (abilities,judgments, costs .,,it expenses whivI PER ISSUANCE 10.00 ' CONST.TAX, '
may in a ec insf said City n consequence of the .
gra ntin rs perm MECH.CONT. LIC.NO. MECH. '
TOTAL TOTAL
Signature of Applica ICo nhactor Uutc '
- OFFICE COPY