3372 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
'Y "!BUI LDI NG PROJECT 1 DENTI F ION _ PERMIT D
So LDING APPLICATION & *MIT - 372
ADDRESS
D BUILDING -ELECTRICAL-PLUMBING--MECHANICAL
/ - -
OWNER'a PLAN CHECK VALIDATION
NAME TV. ELECTRIC PERMIT, FEE
PHONE S=
cgMERA Tags OUTLETS-SWITCHES-RECEP. 5.00/1.00 �// /�✓/�V 3
11C.NO 914 � LIGHTING FIXTURES • 5.00/1.00
ADDRESS APPLIANCES-RESIDENTIAL 4.00
ADDRESS"J �(�
v TF PH°N S PANELS 5.00 _ DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN LHECK FEE P.C.NO.,
OR
ENGINEER
. ITT.No 4e SIGNS TRANS. 3.00
ARCH.
Ess ENG, SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
(, ZIP5w TEMP.METER OIFPAJOIS. 15.00
APPLICANT'S MOTORS SEE FEE SCH.
ADORE
SERVICE C E 6 10.00
woo ' LICENSED CONTRACTORS DECLARATION /� / / �•�j
<v I hereby affirm that I am licensed under provisions of Chapter 9 ELfdL ,Qpf It1� P�q NCE GATE
Z, w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELIECT. 1 PLG. I MECH.
ZProfessions Co e,aRit my license is in full for a J e eciy
o i`vs' W License Class Lic.Number ®:
Date Contractor
a y f BUILDING PERMIT
a Q w a 1114
OWNER-BUILDER DECLARATION O MATION
o a." MISC.- REFER TO ORD
F.
; y I hereby affirm that I am exempt from the Commetor a License V,
Fuo ¢ Law for the following reason.(Sec.703L5,Business Professions PERMIT ISSUANCE 6.00 G_
Code:Any city or county which requiresa permit toconstnmL alter.
a ¢Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. ,IC.NO. ELEC. /4_� _
DLL requires the applicant forsuch permit to file a signed statement that TOTAL ��' PERMIT TO
whe is licensed pursuant to the provisions of the Contractors License
F i Q Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
f S O STORIES TYPECONSTR.
rc H m the basis for the alleged exemption.Any violation tTO TOT civil
en L5
by any applicant fora permit d.Ilarsthe$500).licam toucivil penalty ALTER-DRAIN -WATER (EA.) 4.00
ofnot more than five hundred dollars(5500)J:
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 OCC.GROUP• RES.UNITS
their sale compensation,will do the work,and ire structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cade:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who dues such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 4.00
mens are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or me. RES IND CON PB Omar
prove for purpose of sale.). INDUSTRIALWASTE INTER. 20.00 ❑ [1 11 11111,as owner of the property,am exclusively contracting with
licensed contractors to construct it,. project(Sec. 7044,Business LAWN SPRINKLERS-194M.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITA O f1/B.00 TRACT NO, PARCEL NO.
❑ I am exempt Linder Soc. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Dale Owner WATER SYSTEM MY Ut 6UPeR11104.00 _DATE ACC.FILE NO.
.� WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
(� I hereby affirm that I have a certificate ofconsentto se1C-insure' ZONING ENG.SITE NO.
a certificate of Workers Compensation Insurance,or a cc
it ifled
ihereof(Sec.3800,Lab.C.I CIVIL
Policy Company_ �� R72
Q 13 Certified nhed-rj Certified copy is hereby fFIRE-SPRINK ENERGY T 24
Z Z - ❑ Certif I.Inis 41ed ,gh�e ufyA spection mokion. MISC.- REFER TO ORD. Y N y N
O Applicant ^ Y ..f9 ❑ ❑ ❑ ❑
p: rn PERMIT ISSUANCE . 6.00 (p " FLOODZONE A.L.U.C.
CC CIiRTI FICATIS OF EXEMPTION FROM WORKERS'
LU _ COMPENSATION INSURANCE PLG.CONTR. ,LIC.NO. - PLG. 'a� O�
d (This section need Dot be Completed If the permit Is for one TOTAL Y❑ N❑ V ❑ INC]
Z hundred dollars(S IOD)or less.)
U O 1 certify that in the performance of the work for which this per DTV. MECHANICAL PERMIT FEE FEE SUMMARY
U. I mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. s.a
O y Data Applicant - ALTER OR ADD TO MECH. 4.00 BUILDING Q
} N NOTICE TO APPLICANT: If,after making this Certificate of P.x-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10p000.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OV SEISMIC FEE 4J�
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WIT U T 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ C.) 7rT \ HEATING UNIT(TO 10
Lender's Name �/LL' _i .fes HEATING UNIT(OVER 100,0008. .U.) ELECTRICC'0
Lender's Address
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county g01LER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
'hereby authorize representatives of this city to enter upon the BOILER-COMP lose,100,000 BTU)SEE FEE SCH. MECHANICAL z CO
above-mentinned property for inspection purposes.
(We) agree to save, indemnify and keep harmless tlse City of MISC.- REFER TO ORD.
Cu ertino against liabilities,judgments, costs and ex enses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00 3 (� _
gr I IT of this ermiL MECH.CONT. LIC.NO. MECH. 8
g - TOTAL 7 J� TOTAL /SJR
h,)I J
Signature at A cant/Contractor Date
OFFICE COPY ..