12962 (2) APP ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
!• ' ' BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
80ILDING - APPLICATION & PERMIT 12962
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNEN'6 PLAN CHECK VALIDATION
• A
QTY. ELECTRIC PERMIT FEE
PHONE Sp(I
CONTRA Rs OUTLETS-SWITCHES-RECEP 10.00/1.00
V NAME
/ Lc.rvoLIGHTING FIXTURES 10.00/1.00
r-orvTRAcroR's I APPLIANCES-RESIDENTIAL 4.00
ADORE56
PHDNE �%� PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER
La No.' SIGNS TRANS. 3.00
AARCH,OR
DDRESS ENG SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ZIP TEMP.METE R POLE INS.` 20.00 alga
APPLICANTS MOTORS FEE SCH.
ADDRESS
SERVICE CHANGE 0.00 / /
Foo LICENSED CONTRACTORS D17CLARATION P S f !
< v w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
v,a A (commencing with Section 7000)of Division 3 of the Business and Cu BLDG. ELECT. PLG. MECH.
o Professions Cod��..and 1��lyy license is in full fore jLa L Y
¢ i F � License Class t„f.Sl..�Lic.Number ❑ ❑
9
Date Contractor
< r E BUILDING PERMIT
a a; M st OWNER-BUILDER DECLARA'T'ION INFORMATION
a'xl y I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
to u o¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires permit to construct,alter,
re improve,Q 0 Improve,demolish,Or repair any structure,prior to its Issuance,also ELEC.CONTR. LIC.NO. ELEC. r.D
in LL requires the applicant for such permit to file a signed statement that TOTAL
n w 8 w he Is licensed pursuant to the provisions or the Contractor's License - PERMIT TO
FIQ Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe E
i 4 D Business and Professions Code)or that he is exempt therefrom and
the basis for the alleged exemption.Any violation of Section 7031.5 DTV. PLUMBING PERMIT FEE
$ STORIES TYPE CON TR.
s ; by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACKFLOW PROTECT.DEV ICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:Tile Contractor's License Law does not apply to an owner of
• property who builds or improves thereon,and who does such work FIXTURES,PER TRAP5,00 6G,FT.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-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of Sale). - INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pe Omar
❑ I,as owner of the property,am exclusively contracting with E_] ❑ 0 ❑ ❑
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 SEWER-SAN EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l 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 NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-houne.
or a certificate of Workers'Compensation Insurance,or a certified. ,ZONING ENG.SITE NO.
copy . ec.3800,LAC,). _1;4. �
Policy er Company'--a"-`L{-
Q No
❑ Cc,
l ilied cop is lteryK, IF nished, d FIRE SPRINK ENERGY T-24
Z Z ❑ Cert ifi c y�jf flQt Ith "I N iq on division.
O Applicant (6�_ / MISC.- REFER TO ORD. Y E3 NED Y ❑ No
N CERTI LATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed it' tile permit is fur one TOTAL Y N V❑ . N
=) Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for'which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued.I shall not employ any person in any manner so as to
O w become subject to the Worker Compensation Laws of California.
C1. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE 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 be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0)000C.RM.) 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,Civ.C.).
Lender's Name
HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC -eel
. 1 certify that I have read this application and slate that 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(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COM P (Over 100,000 BTU)SEE FEE SCH, MECHANICAL
(We) agree to save, milenmify and keep barmless the City of MISC.'- - REFER TO ORD. -
Cupevine against Babilifies,judgmer s, costs nd expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way acer{�e against sal ity 1 nsequen a of[he
grand u� to iV MECH.CONT. LIC.NO. MECH.
G TOTAL TOTAL I/
Signa a of p aan/Contractor fie
OFFICECOPV -