8292'�' L T TO FILL IN INFORMATION WITHIN RED LINES - USE BALL PUIN I rely UINLY
PLICAN
PERMIT NUMBER
,dA. BUILDING PROJECT I DENT[ FICATI ON
APPLICATION & PERMIT
-ELECTRICAL- PLUMBING - MECHANICAL
-
ELECTRIC PERMIT o..i1 v c' ,µ?EE .
8292
(, 2
PLAN CHECK VALIDATION
DATE ON
CKF APPLICATIO
PLAN CPEFEE P.C. NO.
PERMIT VALIDAI ION
_
`� r
j
IS DANCE DATE
BLDG. ELECT. PLG. MECH.
❑'
BufuIi�DTI�Nc ///'�axy
A01'i52.3� v C1 eckBUILDING
OwHER's Lwi V J
MEIn ��
a� U
R CTOR'S
a4 -w Q0 Ib C. No42�58o
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
AU E55606 , I ^,v�',p-'I ��
V E
ARCHITECT
ENGINEER
LIC. NO.
ARCH, OR ENG.
ADDRESS
" ZIP
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
PANELS (OVER 200 AMPI 20,00
SIGNS TRANS. 3.00
SPECIAL CIRCUIT 5,00
EMP. METER OR POLE INS. 20.00
APPLICANTS
AU RE55 I� CI
�1{Ik�JI(xV1shwn
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00a
LICENSED CONTRACTORS DECLARATION
1 hereby affmn ]hat 1 'am licensed under provisions of Chapter `)
(commencing w'It Section 70001 01 Diviau+ J of th�usiness and
Pralessions C , u license is in full 1'
TEMP. POLE 30.00
Lice's lass�� Lin. Numl`T7_fG1-W-
Date Contract. l..J�k•/•11f1JesA'u
OWNER-BUILUER DECLARATION
I hereby affirm that 1 ase exempt from the Contractor's License
Law for the following reason. (Sec. 7071.5, Business and Proicssions
Cade: Anycity orcounfy w1iichre4uiresapennit to ons]ruct,3hcq
improve, demolish, or repair any structure, prior to its Issuance, also
requires the applicant fur such permit W file a signed statement tiut
he is licensed pursuant to file pvisions of the Cun Ra,mr's License
Law (Chapter 9(commencingwith Section 7000).1 Uivisiun3ol'the
Business and Professions Code) or that he is esen]pt therefrom and
the basis for the JIICgrd exemption. Any violation of S,ct]Un 7031.5
byanyapplicent lora permit subjects the applicant fila civil penally
Uf nDl nnm, tha]1 five liundred dollars (S50D).):
❑ I. as owner o1 the property, or my employees with wages as
their sale compensation, will do the work, anti the 1,me W re Is nut
Intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractors License Lew does not apply to an owner of
1limxell or Ivuugh his ilea. a npluyeeL I+rovnleJ t]Imtsuehlimp.uve
hoveethebudding
intcndedfo vel:
'-BUILDING P E RM IT$„?'?i(ir
`•INFORMATION,. 'IJ
MISC. - REFER TO ORD
VALUAT]ON
f/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTE. LIC NO.
ELEC.
TOTAL
P q IT TO
-' .,.'+FEE'1
OTY. PLUMBING PERMIT:'. ,;;•,-'f::*, ;t _
' - a "
STORIES
TYPE CONSTR.
ALTER-nRe"^saa.y �'+-VFMT-WATER(EA.) 5.00 -'
BACK FLOW PROTECT. DEVICE 4.00
---UCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES -PER TRAP 5.00
56 FT. FLOOR AREA
TOTAL ACREAGE
.
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
nb sere not oralferedrvalalh
improvement is sold within one year of completion, ]hr owner-
ilder will have Of e burden of proving that he did not build or it"
prove for purpose a l' sale).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors It construct the project (Sec. 1044, Bminess
rofessions Code: The Contractor's Licamv Law docs net apply
and Professions(,
to an owner of property who builds or improves thereon, and who
contracts for such projectswi0lxcontmetorls)liccnsdpursuant to
the Contractor's License Law.
❑ IamexemptunJcrSec, ,B.61'.C.I'nrGds
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PR Omar
❑ ❑ ❑ ❑ ❑
_
INDUSTR IAL WAST�INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B,, 6.00
ASSESSORS PARCEL NO.
s-
LAWN SPRINK V FTR 5.(EA.) R s 1.00
SEWER-SANITARY-STORMEA. 200ft/10.00--TRACT
NNO.
PARCELNO.
WATER HEATE r / gN,upe 6.00
reason
Owner Date
WATER SYSTEM 5.00
ALL. DATE
ACC. FILE NO.
WORK ERS'CONIPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
20NING
ENG. SITE NO.
I hereby affirm taut I have a certificate of consent to self -insure,
Ora certificate of Workers' Compe�r�y tion [,is cc, or a unified
Cupb.0 7C -
Po11cparty1.:.lrl�J f..a
IfIMKL
❑ cliff 1 copy is hereby turn d.
ort s will v 'lion division.
App
FI RE SPRINK
Y ❑ N ❑
ENERGY T24
Y ❑ N❑
MISC. - REFER TO ORD.
ca�-
CIiRTIFICATf:OF EXEMPTION FROM WORKIiRS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundleddollms($100)urlrs,)
1 certify that in the performance of IIIc wild for which this per
mit is issued, I shall not employ any person in any manner so as to'--"
become subject to the Workeri Compensation Laws ul California.
Date APPlicant
NOTICE TO APPLICANT: If, after making this Certificate of lix�
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must flovith comply with
such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a emis0uctian lending agency'lor
the perlormanm of the work lar which this Permit is inued ISce.
3097, Civ.C.L
Lender's Name
PERMIT ISSUANCE TORO -
FLOOD ZONE
YE] N❑
A.L.u.C.
Y❑ N❑
PLG. CONTH. LIC. NO.
TOTAL R
,.
�;�„
CITY.\' ",MECHANICAL PERMIT � FEE
.\ .. ", .\: ,.-., . -
.'.'FEE SUMMARV,I'
BUILDING
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT IT 1Op00GF.M.) 4.00
SEISMIC FEE
AIR HANDLING UNIT(OVER 10000C.F.M.) 6.00
EXHAUST HOOD (WITH DUCT) 5'00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
ELECTRIC
HEATING UNIT (OVER 100, 000 B.T.U.) 9.50
Lender's Address
I certify that I have read thisapplication unit stale that the above
'information is correct. 1 agive to comply with sell city and county
VENTILATION FAN (SINGLE) 4.00
PLUMBING
i
BOILER• COMP13 H.P, or 100,000 B.T.U.) 6.00
MECHANICAL
"
ordinances and state Paws relating to building construction, and
hereby authorize representatives ol'this. city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to mso, inder....ify send keep harmless the City ul
CuPerti uguinsI 11,din ilio, judgments, costs and expenses whi'h
an ry wuY accrue against said ity in consequence of the
gr or g 115 em 1. ,..,/
���_[I�t�{/y�"(/J���_ I IX.CVJ1
BOILER -COMP (Over 100.000 BTU) SEE FEE SCH.
MISC. - REFER TO ORD.
CONST. TAX
TOTAL.
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO. MECH.
TOTAL.
Signature 'APPIi+'+setic.onu'lur Uljr��l--
OFrR.E ear