16597 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
UI LDMG PROJECT IDENTIFICATI ONPERMIT NUMBER
pD,LD,NG APPLICATION & PERMIT
rNOR ESS } Irk `n'I
S . SRA - BUILDING-ELECTRICAL-PLUMBING -MECHANICAL' L> 16 5 5 7"
W' NWMER - ) PLAN CHECK VALIDATI N
�G L4Dg 3� / QTY. ELECTRIC PERMIT FEE !�/
PHONE PJb l /
NAME, CTOR'S 1
NAMEOUTLETS-SWITCHES-RECEP 10.00/1.00 /p� C�
C.NO. LIGHTING FIXTURES 10.00/1.00 1 72- 7
C J _
---- -- CONTRACTOR PPLIANCES-RESIDENTIAL .4.00 1
ADDRESS
t PHONE PANELS 10.00 DATE OF APPLICATION' -^•
ARCHITECT --- FEE P NO.
N CHECK-7
PANELS (OVER 200 AMP) 20,00 PLA .C.
NGINEER
LIC.NO. SIGNS TRANS. 100
ARC H.OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT rs
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
PAI D
w o S - LICENSED CONTRACTORS DECLARATION
- WU u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
1 Nay (commencing with Section 7000)of Division 3 of the Business and-
/119^ BLDG. ELECT. PLG. MECH.
` F N z Professions Cole,and my license is in full torte and effect ❑ -❑ ❑
go w O License Class Lie.Number
Date Contractor
u f t City,of C pertino BUILDING PERMIT
¢ ¢O u o OWNER-BUILDER UECCARATION INFORMATION
w ;LL N I hereby afllnn that I um exempt from the Contractor's License MISC.- REFER TO ORD
r u o J Law for the following reason.(Sea 7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
i Code:Any city or county which re9uiresa permit to construct,alter,
QQQQ Improve,demolish.Or repair any structure,prior to its issuance,also ELEC.CONTR.' LIC.NO. ELEC.
l �ODV
wD LL requires the applicant for such perm it to file a signed statement that TOTAL PERMIT TO
. m he Is licensed pursuant to the provisions of the Contractor's License -
Hir Law(Chapter 9(commencing with Section 7000)off)ivisi.n 3 of theQ.
f i o Business and Professions Code)or that he is exempt therefrom and GTV. PLUMBING PERMIT FEE e.
¢,I-e� the basis for the alleged exemption.Any violation of Section 7031.5 STORIES ` TYPE CONSTR.
n ; - by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than live hundred dollars($500f):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES,UNITS
c 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 Cor tmoor's License law does not apply to an owner of
JL�+ 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-
mentsare'rot intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA) 200 BUILDING USE
builder will have the burden o(proving th . . .
Iliac he did not build or im- RES IND CON PB 'Other
7.pforpurpose of salt.). . INDUSTRIAL WASTE INTER. 30.00
1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 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(EA.) 1.00 '
contracts for such Projects with a enntmatnd sl licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL N0.
L
'❑ lure exempt under Sue. ,N.&P.C.for this WATER HEATER W/VENT 6.00
reason
Own Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
Wo ER COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm at 1 have a certificate.1 consent to sqf-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy dmreof(Sec.3800,Lab.C.). - -
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T20 _
Z 0 Applicant Cified copy is filed with the city inspection division. MISC.- REFER TO ORD. Y N Y N
F rn PERMIT ISSUANCE 10.00FLOOD-ZONE❑ ❑ ❑ ❑
� CIiRTIFICCOMPE COMPENSATION
INS FROMWORKERS' A.L.U.C.
W � COMPENSATION INSURANCI' PLG.CONTR, LIC.NO. - PLc.
CL o (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
D Z hundred dollars IS 100)or less.)
(„) O I certify that in the performance of the work for which this'per- DTV. ' MECHANICAL PERMIT FEE FEE SUMMARY
U. U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workeri Compensation Laws of California. / a
y Datc Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING /6 Za•d
} N NOTICE TO APPLICANT: If,after making this Certificate of F;x-
I._ Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 rELECTRIC
CHECK Q
provisions of the Labor Code, you must forthwith comply with �j�L �'
U such provisions or this Renoir shall be deemed revoked. AIR HANDLING UNIT(TO 10O00C.F.M.) ,4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 IC FEE 0
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. FILM
3097,Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 6,00
Lender's NaH EATI NG U N IT(OV ER 100,000 B.T.U.)9.50Lender's AdJress
Jr I certify t11at I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00information is correct. I agree to comply with all city and countyBING
ordinances and state lows relating to building construction, and BOILER-COM P(3 H.P.Or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
Cx , above-mentioned property for inspection purposes.
(We)-agree to save, indemnify and keep harmless [be City of MISC.- REFER TO ORD.
'= Iipeitino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue a aimst/bald City in consequence of the
ren gOf thispermit- ; p MECH.CONT. LIC.NO. MECH.
•VLVY,Iv� "�b^/1-0-� TOTAL TOTAL /,y!
gnature fAppf nt/Contractor Data
OFFICE COPY