18876 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
.PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
BUILD
Ixc I 0 I v
°r5
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
OWNER'S
NAME .1 TV. ELECTRIC PERMIT FEE
PH
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.. LIGHTING FIXTURES 10.00/1.00
CDNTRACT R'S PPLIANCES-RESIDENTIAL 4.00
DDRESa
SH PANELS 10.00 DATE OF APPLICATION
A c PANE LS I OVER 200 AMP)
20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER SIGNS TRANS. 3.00
LIC.x0. PERMIT VALIDATION
ARCH.OR ENG.
ADDRESS CIRCUIT 5.00
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. S C
ADDRESS
SERVICE CHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARATION x
¢u U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y a N (commencing with Section 7000)of Division 3 of the Business and / 7 .�.��J BLDG. ELECT. PLG. M H.
D Professions Colla _ y license is in full f,.ex itff
z
0!2 z License CI l� Lic.Number CCJJIIJJ-��
o w Date Contractor_ ��L- -
'-"E W, � Of (snnO1fi017 BUILDINGPERMIT
¢ 2 w¢ OWNER-BUILDER DECLARATION
u REFER TO ORD INFORMATION
w3"i- 1 hereby affirm that I am exempt from the Contractors License MISC.- 4VALUATION S/FT.
,a u O Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requiresa permit ro construct,alter,
¢ ¢<o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC,NO. ELE C.
It
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT O
E
$ be is licensed pursuant to the provisions of the Contractor's License
iii Law(Chapter 9(commencing with Section 7000)of Division3 ofllm
4 o Business and Professions Code)or that he isexempt therefrom and OTY. PLUMBING PERMIT FEE
¢r$ the basis for the alleged exemption.Any violation of Section 7031.5 ES TYPE CONSTR.
A. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
.fact more than Ove hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC,GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA.COND. 5.00
Code:The Contractor's License Low does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP S.DD 6D.FT.FLODR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
ments are not intended or offered for sale.If,however,the building
k or improvement is sold within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4(EA.1 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIALWASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ 1,as owner of the properly,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPR INKLERS-1 INC 5 V.B. 6.00 AWESSORS 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(EA.) 1.00
contracts forsuch projectswilha contracror(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or is certificate of Workers Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z ZC) Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. Y❑ N❑ Y ❑ No
Applicant
CCN CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE _ FLOOD ZONE A.L.u.C.
jyj >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. ' (/. r❑ N❑ r❑ N❑
CL 0 (This section need not be completed if the permit is for one TOTAL �[
Z) Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ'any person in any manner so as to
Ow become subject to the Worker Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
>_ N NOTICE TO APPLICANT: IL after making this Certificate of Ex- 5.00 PLAN CHECK
? emption,you should become subject to the Workeri Compensation APPLIANCE
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 10J.I QF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that 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. HEATING UNIT IT0 100,000 B.T.U.) 6.00 MICROFILM
3097.Civ.C.).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I Certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city' to enter upon the BOILER-COMP IOver 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
uperrino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
ay in any way accrue against said Ciry iu consequence of the
Of this permit lJ MECH.CONT. LIC.NO. MECH.
(� TOTAL TOTAL (�Q 0
of Applicant/Cont C r Dat
OFFICE COPY