10087 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFIC
& PE T
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
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10087
-BUILDINGAPPLICATION
AORF DC7
r OW ER'SPLAN
NAME y-
QTY. ELECTRIC PERMIT FEE
CHECK VALIDATION
PHONE
pA�p -
NAME+AcroRs
OUTLETS -SWITCHES -RECEP 10.00/1.00
' uC. NO. 1
N 3 1986
INJAN
" ~ DATE OF APPLICATION
LIGHTING FIXTURES 10.00/1.00
ADDREACTOR (]'s e[ 6� JYri
Lj /A." F- PHONE - -44#
APPLIANCES - RESIDENTIAL 4.00
10.00
ogCH ECT
ENGINEER
LIC.NO.
PANELS (OVER 200 AMP) 20,00
Pj`�[j 101 F � P.C.NO.
Vr�), 0��I
SIGNS TRANS. 3.00
ARCH, RENG.
ADDRESS
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
('' �p
IR fjlu't.� ' ^ _ . -
APPucANT's
AGGRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION .
TEMP, POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code d my ]seense is in full force en f e t
License Class Lia Number
15SUANCE DATE
BLDG. ELECT, PLG. MECH.
❑ ❑
Dete_f_1 - Contractor
BUILDING PERMIT
INFORMATION
O N R-BUILDFift DELLA ION
1 hereby affirm that I am exempt from the Contractors License
Law for the following reason. (See. 7031.5, Bisinessand Professions
Code: Any city or county which requires a permit loconstruct, alter,
improve. demolish, or repair anyslructure, prior to its issuance, also
requires the applicant for. such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that lie is exempt therefrom and
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
nn
(JDO.r
$/FT.
ELEC. CONTR. LIC. NO. ELEC.
TOTAL
QTY. PLUMBING PERMIT FEE
PERMIT TO
lFt
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (55001.1:
STORIES
TYPE CONSTR.
_
gLTER-DRAIN-WATER IEA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves (hereon, and who does such work
himself or through his own employees, provided that such improve.
ments are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 5.00
IGAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
SO, FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one yen, of completion, the owner-
builder will have the burden of proving that h e did not build or int-
prove 1'or purpose of sale.).
❑ I, as owner of the property, sin exclusively contracting with
- . ..
GAS EASYSTEM -OVER 4 IEA) 200
BUILDING US
RES IND CON PB Other
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the proicct (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who bonds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contractors) licensed pursuant to
the Contractors License Law.
❑ l am exempt under Sec.-, BAP.C. for this
reason
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC.OATE
ACC. FILE NO.
WORKERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of c.nwRt to self -insure.
or a certifu:ate of Workers Compensation Insura r a cert'fied
copy thereof l Sec. 3800, Lab.C. 1.
ZONING
ENG. SITE NO.
Policy No. Company
❑ Certified copy is hereby furnished.
Certified copy I 1 d th tum vjfy.. upectiOR div sum.
A plicin(__t[1� y
FIRE SPRINK
Y ❑ N ❑
'ENERGY T-24
Y ❑ N❑
MISC. - REFER TO ORD.
C1 RTIFI E OF EXEMPTION PROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
PLG. CONTE, LIC. NO.
PLG.
TOTAL
Y ❑ NC]
Y ❑ N ❑
hundred dollars IS 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
/
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become subject to the Workers' Compensation Laws of California.
DaleApplicant
NOTITO APPLICANT: If, after making this Certificate of Ex-
CE
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
emplion, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith Comply with
such provisions or (his permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT (OVER 101300C.FM.) 6.00
SEISMIC FEE
t
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
HEATING UNIT (TO 100,000 B.T.U.) 6.00
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.CJ.
MICROFILM
Lender's Name
HEATING UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
_
Lender's Address
VENTILATION FAN (SINGLE) 4.00
I certify that 1 have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building conslru011o0, and
PLUMBING
BOILER-COMPI3 H.P. Or 100,000 B.T.V.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
gOILER•COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
(We) agree to save, indemnify and keep harmless the City of
C Perrino against liabilities, 'udgment. osis and expenses which
Y i any w' accrue a in i y inconsequence f c
g 1 of this -r sit. N�
aTOTAL
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO. MECH.
TOTAL
I as
a of planar/Clint
actor Dale
V OFFICE COPY