12893 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON PERMIT NUMBER
a11ILDING APPLICATION & PERMIT
12893
AODREss
BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
OwN-Ey's PLAN CHECK VALIDATION
• NP/"y//'D / n. 7173 QTY. ELECTRIC PERMIT FEE
Corvr cons LTi _ / /�
N4 UTLETS-SWITCHES-RECEP 10.00/1.00
// )� Y S
LIGHTING FIXTURES 10.00/1.00
cory ACT 'S /i z PPLIANCES-RESIDENTIAL 4.00
— 4277 //' vHONE PANELS 10.00 DATE OF APPLICATION
RCHITE CT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGIN N
uc.NO SIGNS TRANS. 3.00
AR c"' NG. SPECIAL CIRCUIT 5.00 PER TION
ADOR
11 zIP EMP.METER OR POLE INS.
a M119
ADD s
A.' Ts MOTORS SEE F SCH. MA(R
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SERVICECHANGE 0 I X
w O o LICENSED CONTRACTORS DECLARATION city RIIIIWWW
a u W I hereby affirm that 1 licensed under provisions of Chapter 9 �In� ISSUANCE DATE
v~i¢n (commencing wLL $eel J000)of Dion 3 o th Bu and BLDG. ELECT. PLG. MECR.
r w i Professions Cod hxense ❑ ❑ ❑
License Class Li . er /,
0 m f w Datc n(, to
a L L /� BUILDING PERMIT
E Ix w OWNER-BUILD,,E/RR INFORMATION
w;LL y I hereby affirm That I am CxFmpt�th Contractor's Liccnse MISC.— REFER TO ORD
LLoo Law for the following reason.(Sec.7031.5,Businessint Professions PERMIT ISSUANCE 10.00 VALUATION�-� $/FT.
� - P, Code Any city orcounty which requiresa permit to construct,alter, G 7s7
2 Q 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT O
u w$ he is licensed pursuant to the provisions of the Contractor'sLicense
Law(Chapter 9(commencing with Section 7000)of Division 3ofthu L)
a Business and Professions Code)or that he is exempt therefrom and DTV. PERMIT FEE
PLUMBING
R F p the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
a_ :m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundhnd dollars($500).):
❑ I,as owner of the property,or my employees with wages as IBACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compena itiun,will do the work,and the structure is not
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 FIXTURES-PER TRAP S.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve. GAS-EA.SYSTEM-1 INCA OUTLETS 6.00
meats are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA) 2,00 BUILDING USE
builder will have the burden of proving that he did not build or im . .
- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the properly,am exclusively contracting with
licensed Contractors to Construct the project(Scc. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCELNO.
and Professions Code:The Contractor's 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 contmaorts)licensed pumnam to SEWER-SAN ITARV-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
the CumLtu mcnsc Law.
❑ Iam empluhder Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason /
Owner- Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK IiRS'COMPENSATION DECLARA'IION WATER TREATING EQUIP. 5.00
I hereby allirm that I Imve a certilicalu f consent to wltamsuru. ZONING ENG.SITE NO.
or a certific: of Workcrs'Com hensatio Ins n'e,or certific I
Copy there
Policy No
Q //pp ��Ceoifi, u ere f FIRESPRINK ENERGYT-24
Z_ Z `� its ` cit p .D MISC.- REFER TO ORD. y� N E3 Y ❑ N[]
F' yApplicant
PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
� — CERTIFICATE OF EXEMPTION FROM WORKERS'
LU 1 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. V❑ NE] V❑ N�
CIL 0 (Dais section need not be completed if the permit is for one TOTAL
D Z hundred dollar 100)or less.)
U O 1 certify at in the performance Of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
mil is I shall not employ any person in any manner so as to
Uw becom a em to the Workers'Compensation Laws of California. BUILDING Lf�
Date Applicant ALTER OR ADD TO MECH. 5.00
} aNOTICE TO AFILICANT: If,after making this Certificate of Ex-
0? eunption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK q C�L
Provisions of the Labor Code, you must to conhply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 4.00
CONSTRUCTION LENDING AGENCYAIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
I heroby affirm that ere is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the purl'orman co oljf work for which this permit is issued(Scc. MICROFILM
3097,Civ C.). C( HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name HEATING UNIT(OVER 100,000B.T.U.)9.50 ELECTRIC
Lender's Address
0 1 eerlify that 1 have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00 1
information is Correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby authorize representatives of this city to ether upon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupert against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may i a way accrue against s City in consequence of the
gra. yJ c iL MECH.CONT. LIG NO. MECH.
Z14,_B TOTAL TOTAL
Signmurc of pPlicantlConlracmr Date
OFFICE COPY