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09834 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER aDILDING APPLICATION & PERMIT AooaEss O G 5- 09834 f}Nn//S otT BUILDING- ELECTRICAL-PLUMBING-MECHANICAL OWNER'S - PLAN CHECK VALIDATION NAME ' r�A/v/ DTV• ELECTRIC PERMIT FEE •(�/ NpMrRAcroR s PHONE OUTLETS-SWITCHES-RECEP 10.00/1.00 I #-�/ /U r✓) Ic.No. S�� LIGHTING FIXTURES 10.00/1.00 ADDRRESS roR's APPLIANCES-RESIDENTIAL 4.00 PHONE - PANELS 10.00 DATE OF APPLICATION ARCHITECT OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. ENGINEER �- uc.NO SIGNS TRANS. 3.00 ARCH.OR ADDRESS ENG. SPECIAL CIRCUIT 5.00 vER TION ZIP EMP.METER OR POLE INS. 20.00 PP qe ADDRESsrs MOTORS SEE FEE SCH. OCT, SERVICE CHANGE 20.00 w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cuperf,no a u I hereby affirm that I am licensed under provisions of Chapter 9 naw (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE F 0 2 Professions Code,Slid my license Is in full force and effect. BLDG. I ELEC PL MECH. oi o W License Class Liv.Number ❑ ❑ m r Datc Contractor Qyf K 2 w OWNIi R-BUILUF:R DECLARATION BUILDING PERMIT LL w 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION u O j Law for the following reason(Sec.7031.5,Business and Professions VALUATION Code:Any city or coon pair my structure permit o itsnissuance,also PERMIT ISSUANCE 10.00 3/Fr. rt Q ¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.COrvTR. LIC.NO. O¢ requires the applicant for such permit to file a signed statement that ELEC. w m w he is licensed pursuant to the provisions of the Contractor's License TOTAL PERMIT O HZ > Law(Chapter 9(commencing with Section 7000)O(Division 3 oflhe E 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE SE r m the basis for the alleged exemptimt.Any violation of Section 7031.5 L. 3 b an applicant fur a T RIES E CONSTR, Y' t pn permit subjects $500).licanuoucivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 "ESUN ofnot more than five hundred dollars the ap li❑ I,as owner of the property,or my employees with wages asBACK FLOW PROTECT. DEVICE 4.00their sole compensation,will do the work,and thestructure is not OCC.GROUP tended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00 Code:The Contractor's License Law docs not apply to an owns,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- SO.FT.vLooa AREA TOTAL ACREAGE meets are not intended oroffered for Sale.11,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 prnving that he did not build or in,'- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE pmvc for purpose of oftileJ. INDUSTRIALWASTE INTER. 30.00 E IND CON PB Omer ❑ d as owner of the property,am exclusively contracting with - ❑ ❑ ❑ ❑ licensed contractors m construct the project(Sec. 7044,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 1.00 contracts for such projects with a contmctods)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ 1 am exempt under Sec. ,BAP.C.for This reason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC.GATE ACG FILE NO. x'o IiRs'COMPENSnnoN 0 cLn RAnoN WATER TREATING EQUIP. 5.00 1 hereby a h t hav@ curliG- e r 'consent to NC or a cert ife c C n surance,or a y-rtificd ZONING copy there eb. JJJpY✓✓✓��_��.��` /ry ENG.SITE NO. Policy No ympa 73 i e op 's Iles in shed. Z Z ❑ C I" cop is PITthe city inspection division. FIRE SPRINK ENERGY T 24 App Ina _ MISC.- REFER TO ORD. Y N Y No ~ t' PERMIT ISSUANCE LU CIiKTIF'ICAq'1; E EXEMPTION FROM 10.00 - FLOOD ZONE A1.U,c. CL W COh1PENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Z (This section need not be completed if the permit is for one TOTAL Y N 0 Y E] N E3 O hundred dollars($100)or Iess.) I certify that in l n performance of the work for which this pts CITY MECHANICAL PERMIT FEE SUMMARY W U mit is issued. I shall not employ any person in any manner so a to FEE Wbecome subject to the Workers'Compensation Laws of California. Q. Dalt Applicant BUILDING >_ In NOTICE TO APPLICANT: If,alter making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 f" ? emption,you should become subject to the Workers'Compensation APPLIANCE provisions of the Labor Code, you must forthwith comply with 5.00 PLAN CHECK FEE U such provisions or this permit shall he deemed revoked AIR HANDLING UNIT(TO 10=11F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 101000GEM.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 the performance of Elie work for which this permit is issued(Sec. 3097,Civ.CJ. HEATING UNIT (TO 100,000 B.T.U.) 8.00 MICROFILM Lenders Name Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC x I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) rrect. I agree to comply with 4,pQ JN' • information is coply, all city and county PLUMBING W ordinances and state laws relating to building construction, Sod BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00 bcreby aulhorirc representatives of this city to enter upon the abovomemioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. ' o against Iia hies,judgments, costs and expenses which CONST.TAX � aY in a y a ue against said City in conseque of the PERMIT ISSUANCE 10.00 granting this pe I MECH.CONT. LIC.NO. MECH. ,.�/1 i ignaturc of Applicant/Contrac or Dale TOTAL TOTAL 60 OFFICE COPY V'�