11406 (2) APPLICANT TO FILL IN INFORMATIONVITHIN RED LINES - USE BALL POINT PEN ONLY
,rjUILDINGPROJECTIDENTIFIC gppLICATION & PE T PERMIT NUMBER
aDILn,NG 11406
• ooREss
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OW ER'S
• 7
NAME PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
CONTRACTORS rRtt�aE 7
NAME I zs^3� UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
f,DNTRACTOn'S
ADORP; ¢/Q�y2j APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITEC
OR PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO,
ENGINEER'
ARCH OR ENG, LIC.NO. SIGNS TRANS. 3.00
ADDRESS SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zlv EMP.METER OR POLE S. 20.00
nooriessTa MOTORS
SEE FEE SCH.
wa i SERVICE CHANGE 20.00
. 09 LICENSED CONTRACTORS DECLARATION 0 I/J
a u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUA E
<, (commencing w' Sec Ion 7000)of Division 3 of the�yBu�siryryss_ypM1-
H w z Professions Co arS license is in full fo fryEl/LC BLDG. €4 E{.T. I.G. MECH.
z O m- License Class Lie.Numher 7 77 J rL}J� O O
0 L t w Dale Contractor
5 Or J BUI ERMIT
p ¢ W O ER-BUILDER UECL A N RMATION
X zs LL„I-r 'I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
H w O¢ Law for the following reason.(Sec.7031,$,Business and Professions VALUATION $/FT.
m� Code:Any city or county which requiresapermitmconstruct,ager, PERMIT ISSUANCE 10.00
Q R Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
A.
o¢ requires the applicant for such permit to file a signed statement that ELEC.
TOTAL
w m¢ hP is licensed pursuant[o the prOvislOas OI the Con UactOr's License PERMIT TO
rz > Law(Chapler 9(commencingwith Section 7000IofDivision3 of the �,// /1���
f ¢ c Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE 1 C
¢s- the basis for the alleged exemption.Any violation of Section 7031.5 STORIE TYPE CONSTR.
n ; by any applicant fora permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE
their sole compensation,will do the work,and the structure is not 4.00 OCC.GROUP RES.UNITS
Code:T
intended or offered for sale (Sec doe Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Tile 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 5.00
himself or through his own employees,provided that such improve- a0.ET,FLOOR AREA TOTAL ACREAGE
ments are not intended or offered for sale.It',however,the building GAS-EA.SYSTEM-1 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 im- GAS-EA.SYSTEM-OVER 4(EA.) 2,00 BUILDING USE
prove lot purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CDN PB Omar
❑ d as owner of the property,em exclusively contracting with El O [J 0 ❑
licensed Contractors od to construct the project(Sec. does Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00
and Professions Code:The Contractor's License Law does not apply ASSESSORS PARCEL NO.
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 contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10,00 TRACT NO. PARCEL NO.
❑reason D
lam exempt under Sec. ,BAP.C.for this %WATER'HEATER W/VENT
Owner 6.00
are WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKF.RS'COMPIiNSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers Compensation Insurance,or a certifi ZONING ENG.SITE NO.
[)' copy thereof(Sec.3800,Lab.C.).
Policy No. Company
❑ Ce k evilly furnished. FIRE SPRINK ENERGY TQa
Z
Z ertif Cop I w' the Y ividon.
l� Applicant MISC.- REFER TO ORD. y ❑ N❑ Y C] N[]
D7 = CERTIFICATE OF :XEMPT'ION FRO ORKERS' PERMIT ISSUANCE 10.00 . FLOODZONE A.L.U.C.
Lu > COMPENSATION INSURA li PLG.CONTH. LIC.NO. PLG
CL Z (This section need not be Completed if the permit is for one I TOTAL Y 0 N V [3 N
U O hundred dollars IS 100)or less.)
I certify that in the performance of the work for which this per- CITY
LL 1- mil is issued,I shall not employ any person in any manner so as to MECHANICAL PERMIT FEE FEE SUMMARY
O w become subject to the Workers'Compensation Laws of Califoulia.
}
4 Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING / SO Z Date i TO APPLICANT: If,after making this Certificate of Ex-
F _ emption,you should become subject to Om Workers'Conspensation APPLIANCE 5.00 PLAN CHECK 111 ,37
Provisions of the Labor Code, you must forthwith comply with
C..1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 110=C.F.M.) 4.00 FEE -
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000 C.F.M.) 6.00 SEISMIC FEE J],I hereby affirm (list there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Ci,C.k RIO
Ma"
IT ITO 100,000 B.T.U.) 8.00
Leader's Name
Lender's Address IT(OVER 100,000 B.T.U.)8.50 ELECTRIC
I certify that I have read thisapplication and state that the shove FAN (SINGLE) 4.00information is correct.1 agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction, and13 H.P.or 100,000 B.T.U.) 6.00hereby authorize representatives of this city to enter n theabove-mentioned property for inspection purposes. P (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agre tosave, indemnify and keep harnsle a City ofREFER TO ORD.Cuperti inst liabilities,judgmentssand penses whichCONST.TAX
nmy in a cencoagainst sa' in c sequence of theNCE 10.00emnf [ perm) LIC.NO. MECH.
\ n i OTAL TOTAL CZ937
J" gitatu Applyyn ontrac(or to
OFFICE COPY