10908 APPLICANT TO FILL-IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
o
a011 IND APPLICATION & PERMIT 1OJO8
STF\/ � /.'/p_ OI V ILDING-.ELECTRICAL—PLUMBING—MECHANICAL
1 OWN[R'l5 C.• 7 ` LV PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
M1 ✓{�V ,PHONE
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
NA E -
J LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S I� APPLIANCES-RESIDENTIAL 4.00
ADDRESS
`G-Gh-GNE&2_—ZZYX r PANELS , 10.00 DATE OF APPLICATION
ARCHITECT PANELS IOV ER'200 AMPI 20.00 ,PLAN CHECK FEE P.C.NO.
OR No.'V J�
ENGINEER I LO�JTv�
SIGNS TRANS. 3.00
ARCH,OR ENG, SPECIALCIRCUIT 5,00 PERMIT VALIDATION
• ADDRESS ,
Z,P EMP.METER OR POLE INS. 20.00 '
• . APPLICANTS - MOTORS - SEE FEE SCH. - PAIR n , -_"1
ADDRESS
L01 WkAAA's i
- ISERVicr CHANGE - "20.00
w 0 a LICENSED CONTRACTORS DECLARATION
M u u I hereby of firm Thal 1 am licmised under provisions 0f ChapteT 9 - BDATE
c a (commencing with Section 7000)of Division 3 of the Busineys and 1 T. PLG. MECH.
0.'. Professions Co�und my Ilei, ix In full I'or el 1 - ❑
Z
O w License Class—rJ Lic.Number— ❑ ❑
o Z H D bale-Z--t-� Conlruclor _.(��
F '^ - VVVIII BUILDING PERMIT
Q w OWNER-BUILDER DECLARATION - INFORMATION
wDa MISC.— REFER TO ORD
a. y I hereby collo that I am exempt from the Contractor's License - VALUATION $/FT.
F u O a Law(or the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 '
Code'.Any city orcounty which requires a permit to construct,alter, 14,�. .-d
Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. - LIC.NO. ELEC.
O LL requires the applicant for Such permit to file a Signed sunlaulN that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions ol'the Contractor's License ,
as Law(Chapter 9(commencing with Section 7000)ofl)ivision 3 ofthe Fi�OL'/xl/�
a Business and Professions Code)or that hu is exempt therefrom and QTY. PLUMBING PERMIT FEE
$ the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
u ; _ by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN 8,VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 -
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Scc. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of '
. properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended oroffend for sale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-'OVER 4 IEA.) 2.00 BUILDING USE
Do will have the burden of proving that he did not build or int- RES IND CDN - PB Diner
prove l'or purpose of sale.). - INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ 1:1 ❑.
❑ I,as owner of the property,am exclusively contracting with
licensed contractors'to construct the project(See.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of properly who builds ar improves thereon,and who LAWN SPRINKLERS-OV ER 5(EA.) 1,00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
Cl lam exempt under Sec ,B.&1l C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
- - ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP- 5,00 ,
hereby affirm that I have a certificate of consent In sell'-inone., -or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG,SITE NO.
-
copythereof( in. 800,Lab.C.I
Policy No. Company - -
❑ Cetlifiedc Rhe eby( fished. - ,FIRE$PRINK ENERGY T"ZC
z Cert p Olt the city inspection division.
Ap licant _ MISC.- REFER TO ORD. y ❑ N❑ y ❑ N❑
~ w PERMIT ISSUANCE - 10.00 FLOOD ZONE A.L.U.C.
CER'fIf ICAT>OP :XEMPTION FROM WORKERS'
W — I COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the.pernit is for one TOTAL V❑ rv❑ V ❑ N❑
Z) Z hundred dollars(S100)or leas.)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f mit is issued,1 shall not employ any person in any manner so as to
U become subject t0 the Workers'Compensation Laws of California. / .-S S7b
0 y Date Applicant ALTER OR ADD TO MECH. ' 5.00 BUILDING /
} to NOTICE TO APPLICANT: If,after making this Certificate of rix-.
? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAWCHECK
V provisions of the Labor Cade, you must forthwith comply with FEE I
such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10A00C.F.M,) 4.00
CONSTRUCTION LENDING AGENCY . AIR HANDLING UNIT(OVER 10=CF.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency foi EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued IS". MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 S.T:U.) 6.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address "ELECTRIC
I certify that I have read this application and state Flat 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-CON11"(3H.P.or 100,000B.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) Oct, to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. i
Cuperti against liabiI tie judgments, costs and expenses which CONST.TAX
m wary rue gainst said City in coreeyuenca of the PERMIT ISSUANCE 10.00
MECH.CONT. - LIQ NO. TOTAL TOTAL
\T/ Sig urco Applic t/Contractor Dale