10874 ''Y'•`r:t APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PROJECT-IDENTIFICATION PERMIT NUMBER
' APPLICATION & PERMIT
ADO E"S'O 10874-
BUILDING
ADOREss a : BUILDING-ELECTRICAL-PLUMBING-MECHAIFIAW or-- NICAL
41 OWNER' ',.•1 a -f I t ' r' ,t' PLAN CHECK VALIDATION -
} "AME ••��//Ea QTY ' ELECTRIC PERMITFEE;':
ONE [i�//i� ':e JA. I:I y}'
co"mnc s OUTLETS
-SWITCHES-RECEP 10.00/1.00
NAME aa�
G'1�eV uC.No. ILIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADGDR ESS
"1`..••� �
`4�.�/ PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT
PANELS 200 AMP) 20,00 PLAN CHECK FEE P.C.NO,
OR
ENGINEIF -
uc.No. SIGNS TRANS. 3.00
ARCH,OR ENG. 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIflCUIT
zip EMP. METER OR POLE INS. 20.00 D -
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 n
y/� 6�
W o 9 LICENSED CONTRACTORS DECLARATION / A
u u I hereby affirm [hat I am Iicenud under provisions of Chapter 9 ISSUANCE DATE
' n 4 y (COmmenUOg with h'l'CtlOn 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
F n Z Profession Co ry license is'in full fol ❑ ❑ ❑
z o Llttnu s Lic.Num -
o= Onto
.i(a-CantmCW _ PAID
r '" BUILDING PERMIT--,
a z W 4 OWNER-BUILDER DECLARATION H.'.,•.KS
U REF �'[,O CORD �INFORMATION.,•.+. .., .
w ; n m I hereby alfinn that I um exempt from the Contraetorl hiceroc MISC.- r. VALUATION $/FT.
r :oJ Law far the following noon.(Set 7031.5,Busincssald l'rufessiuro PERMIT ISSUANCE 0.00 O
Code:Any city or county which requiresa permit to construct,alleq
R ¢ Q G Improve,demolish,or repair any slruciure,Prior to its issuance,also ELEC.CONTR. LIC NO.
requires till'applicant for such perinit to IIIc a signed slale111Cn1 that City of Cupe YaarML 3 Q PERMIT TO
wm w he is licensed pursuant to the provisions of the Contractor's License ,
rir
Law(Chapter 9(commenciagwith Seulnn1000)ofUWlsiun 3 of th r 1 }, ' ' + +a - rT �CNT�r N�CG�
a Business and Professions Code)or that he is exempl Iherefroln and DTV. 1 'PLUMBING PERMIT, 'n.iY: I FEET.'
r $ the basis for the alleged exemption.Any violation of Section 7031.5 d: "" '' f r.'+ )+. }t ',r' STORIES TYPE CONSTR.
of an mopetlwnar hundred doledollns(ESIIOj)°antwaCivilpawlty ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑nol 1,as owner of the property,or my employees With wages as BACK FLOW PROTECT. DEVICE 4,00 OCC.GROUP RES.UNITS
their sine compensation,will do the work,and the 41.11.1c H nut
intended or offered for sale tSec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 - --
Code:The Contractor's License Law does not apply to ion owner of
property who builds or improves thereon,and who dues such work FIXTURES-PER TRAP 5,00 Co.FT.aooR AREA TOTAL ACREAGE
'-, himself or tI gin his own em PloYees.provided than such illlProvu-
menu are not intended or offered for sale.If.Imwevar,the building GAS-EA.SYSTEM-11NC.40UTLET$ 6,00
R bnpruvelnent is sold within one Ycar of connpletion,the owner
builder will have the burden of proving that he did not build or an- GAS-EA.SYSTEM-OVER 4(EA.1 2.00 RES IND BUILDING USE
Oma,
Prove for purpose I INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ 1,as owner Of the properly,.am exclmively contracting Willi
Iicenud cuntraelors to construct the project 1Sce.7044,Bluffness LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL No.
and Professions Code:The Contractor's Li,ensn Law does nal aPply
to an owner of property who builds or improves dercou,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
Contracts for such projects with a conlnetoos)licensed pursuant to
the Cmstrucwr's Lice nse Law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
❑ Ism exempt under See. ,B.&1'.C.lar this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC,DATE ACC.FILE NO.
WORT ERscOMPENSATIONb[CiARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a Certificate of Consent lu all'-insure, ZONING ENG.SITE NO.
or a ce f 'o k' 'Compensation Inmnnce,or a Certified
cop let Su tvC.L
P icyNr I P-ab, Le
_ O ❑ Certified I Y
Zle IbY wish I 'i - t division FIRE SPRINK ENERGY T-249
Z MISC. REFER TO ORD.- Y❑ N❑ y ❑ No
Z OOJ APPlica - -
CC C TIFICATE OF EXEMPTION FROM WOKKI`-RS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
LD._ COMPENSATION INSURANCE PLG CONTR LIC NO. PLG
CL O his section need not he complete) f the pcmnil ns lar o m TOTAL Y -] N❑ Y❑ N❑
Z hundred dollars($IOW,or less.) _
U O I certify that in the performance of the work fm which this l r OTY. s MECHANICALrPEflM1T }y*v FEE: - 't'r 1' ' FEE SUMMARY
U. f roll is issued,I shall not employ any pc,UHR in any namner so a'ill 11 a .:
OW become subject to the Workers Cmnpensatiun Laws of California. "" - " h BUILDING
Data Applicam ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If,alter making this Certificate of nix-
? Cmp!ion,you should became subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you mus[ forthwith comply with FEE
U - such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10p00C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,ODOC.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency far EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(See MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and stale 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 authorise representatives of this city to enter upon Ilia BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
[ioned PmPc,i, for inspection purposes.
An�.Nyi'nin
Icsave, in. nnil'y and keep Imnuless the CI1) of MISC.- REFER TO ORD.
ns liabiliti., udgns ts, curb and expensss w ich CONST.TAX
accru aga hs 1 City it, conseyucn • oP the PERMIT ISSUANCE, 10.00 h it. ,x + MECH.CONT. LIC.NO. MECH.
_ '!// OTALTOTAL
pplicant/C'ontraclor Dale
FFICL UCUPY