12400APPLIG4NT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
-
APPLICATION & PERMIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
12400
Bast ING _
aooRE
J
OwrvER'S
NAME
t V [,. /—E ? w PHONE
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTORS
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
/L .NO.
DATE OF APPLICATION
CONTRACTORS
A a T.
PHONE
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
ARCHITECTPLAN
OR e (
ENGINEER
PANELS (OVER 200 AMP) 20.00
CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENGSPECIAL
ADDRESS
CIRCUIT S.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP A
^
(2,o—', v;"
APPLICANTS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
Rio
��,�% �
LICENSED CONTRACTORS U !&ARATION
1 hereby affirm that I am licensed under provisions of Chapt 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code a my licensC is in full far -
' License Class_ Lic. Number ✓`/
ISSUANCE DATE
BLDG. ELECT,
El❑
PLG. MECN.
ElDate
Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License
Professions
Law for the ity followingreason.whichequire .a permit to
Code: Any city or county which requirese permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
isles the applicant for such permit to file a signed tlemeN that
he en
he is licensed pursuant [he provisions of the Contracactor's License
of Division 3 ofthe
Luca (Chapter 9 (commencing with Section is exempt
Professions Code) or that he is exempt therefrom and
Business and
BUILDING PER
INFORMATION
MISC.— REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION $/FT.
ELEC. CONTE. LIC. NO. ELEC
TOTAL
QTY. PLUMBING PERMIT FEE
PERMIT
for
the basis for the alleged exemption. Any violation of Section 703malty
STORIES
TYPE CONSTR.
$5applicant tDacivil penalty
by any more
for five
of not mom than five hundreJ Dollars ($$00)J:
hundred dollars
..
ALTER -DRAIN VENT -WATER (EA.) 5.00
❑ I, 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
intended or offered for sale (Sec. 7044, Business and Professions
DRAINS -FLOOR, ROOF, AR EA, 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
himself or through his own employees, provided that such improve-
mentsare nmintended oroffered for sale. If, however, the building
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or am.
prove for purpose ofsale.).
❑ I, as owner of the property, on exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB omar
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30,00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
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
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
SEWER-SANITAR V -STORM EA. 200ft110.00
TRACT NO,
PARCEL NO.
❑ lam exempt under Sec.—, BAP.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKF-RS'COMPF.NSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compe sahon nsurance, or a certified
ZONING
ENG. SITE NO.
copy ($ iFab CJ
Polic any,
FIRE SPRINK
Y ❑ N ❑
ENERGY T44
v ❑ IN
f2 ertilie copy is hereby nnishcd.
er led copy, i it, the city inspection division.
Applicant
MISC. - REFER TO ORD.
TI CATE - ?XEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG. CONTE. ❑C. NO.
PLG.
TOTAL
COMP gNSATION INSURANCE
(This section need not be completed if the permit is for one
Y ❑ N ❑
v ❑ N ❑
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD 5.00
APPLIANCE 5.00
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 UNI IT 10 .M.) 4.00
AIRHANDLIN VERq10 .16.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a Construction lending agency for
EXHAUST HOOD (W I tl 1 5,00
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.L
MICROFILM
HEATING UNIT (50,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)9.50
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
ordinances and state laws relating to building construction, and
PLUMBING
BOILER- COMP (3 H.P. Or 100,000 B.T.U.) 6.00
BOILER -COMP (Over ,.
100 000 BTU) BEE FEE SCH
H
MECHANICAL
Lam`
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
(We ree to ave, indemnify and keep harmless the City of
Caper no again liabilities, judgments, costs and expenses which
may n any a aga st said City in consequence of Me
CONST. TAX
PERMIT ISSUANCE 10.00 C)
gmn in si a it.
!�
MECH. CONT. LIC. NO. MECH.
TOTAL �-64,TOTAL
a I p scant/Contractor ate!/
OFFICE COPY