9272 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• BU I LDING P.$OJECT I DENTI FI ATIO PERMIT NUMBER
BUILDING ^Qjyl APPLICATION & PERMIT
ADDRESS
_ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 9272
OWNER'S PLAN CHECK VALIDATION
"AME QTY. ELECTRIC PERMIT FEE
ev
X l o"TRAcrosNse ' UTLETS-SWITCHES-RECEP 10.00/1.00
c -37;77t / LIGHTING FIXTURES 10.00/1.00Q aiy
V
CONTRACTORS- I O$- PPLIANCES-RESIDENTIAL 4.00
ADDS E 5 t�
//•f 14�$ $SLE A- VHONE a63 s�vy PANELS 10.00 DATE OF APPLICATION
ARCHIIEC % PLAN CHECK FEE P.C.NO.
OR
e �/ PANELS (OVER 200 AMP) 20.00
ENPAIDGINEER
pl.¢.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT (DATION
ADDRESS SPECIAL CIRCUIT 5.00 19�
ZIP EMP.METER OR POLE INS. 20.00 o
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS.
SERVICE CHANGE 20.00 ity of CuDe000
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
< vU I hereby aRinn t1Wl I um licensed Under provisions of Chapter 9 ISSUANCE DATE
HC w EL(commencing with Section 7000)of Division 3 of the Business and
w z BLDG. CT. PLG. MECH.
H Professions Code,and my license is in fall for c,4' &rtpl ❑ El
❑
z o m- License Class Lic,Number J
L H w Date Contractor fe`A
`¢ y s BUI DING PERMIT
¢ w ¢ OWNER-BUILDER DECLARATION I FORMATION
,, 3. MISC.- REFER TO ORD
0 H I hereby affirm that I am exempt from the Contractor's License VA ATION $/FT.
a, .. ov, Law for the following reason.(Sec.703 L5.Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
¢ ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ic
D M requires the applicant for such permit to the a signed statement NIDI TOTAL PERMIT TO
A w m u, he is licensed pursuant to the provisions of the Contractor's License
Fz � Law(Chapter 9(commencing with Section 7000)of Division 3oftlia
- ¢ Business and professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
4 D STORIES T PE CONSTR.
¢ $ by basis for the alleged exemption.Any violation of Section malty
d ; - by any applicant fora permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,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 Law does not apply to an owner of
. pro Perry who builds or Improves themon,and who docs such work FIXTURES,PER TRAP 5.00 SO,IT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the harden of p.vmg that he did not build or in„ RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,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 contractors)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO. PARCEL NO.
❑ [am exempt under Sec. B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Comp7at ion InsI I nee,or a cert ificd ENG.SITE NO.
copy therepIi,n� /
NoNti / t b _kArf
O ❑ tilic ' yfurnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Ce ificd 'e BI- .with tcity inspection division. MISC.- REFER TO ORD.
O A,plicant - Y ❑ N❑ Y ❑ N❑
~ va PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
Cl'. IFICAIEOF EXEMPTION FROM WORKERS'
W _ CO MPFNSA'1'ION INSURANCE PLG.CONTH. LIC.NO. PLG.
d a (This section need not be completed if the permit is for one TOTAL V❑ N❑ V❑ N❑
Z huhtlred dollars IS 100)or less.)
U O 1 certify that in the perlarmance ol'the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H 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.
Go Dme Applicam ALTER OR ADD TO MECH. 5.00 BUILDING
>_ to NO"rl Chi TO APPLICANT: If,after making this Certificate of Ex-
F. Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith Comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10jW0ORM.) 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(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Ci,C.).
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that 1 have read this application and state(but the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or10O,000B.T.U.) 6.00
hereby authorize representatives at this city to eller upon the BOILER-COMP (Over 10Q000 BTU)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.
CuterIfirm against liabilities,judgments, coVs and expenses which CONST.TAX
ay in any way accrue against sand y in consequence of the PERMIT ISSUANCE 10.00
g nting o is P miL MECH.CONT. LIC.NO. MECH.
-7/z'f1r' TOTAL TOTAL
Signa re of Applicant/Contractor Date
OFFICE COPY