13456 (2) APPLICANT TO FILL IN INF Q ATION WITHIN RED LINES- USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT(FIC N PERMIT NUMBER
APPLICATION & P IT 13456
ADD Ess ` BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
OWNER'S
E - OTY. ELECTRIC PERMIT FEE
PHONE
CONTR ORs UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
sec.NO, p? LIGHTING FIXTURES 10.00/1,00 ,09
r; 'TRACTOR'a'"f l71 APPLIANCES-RESIDENTIAL 4.00 A41,Q
(`
PHONE Z.{ PANELS 10.00 1! GATE OF APPLICATION
25KARCHITECT PLAN.CHECK FEE P.C.NO.
OR PANELS IDV ER 200 AMP) 20.00 ���T _,�
ENGINEER SIGNS MRAN3.00
sec.ND.
ARCH.OR ENG. .00 C' I�PERMIT VALIDATION
ADDRESSSPECIAzIP EMP. 0.00 K�j (/1,t-t'qAvvucANr's MOTOCH. G° ` ' p`'U���+ADOREUICII((]5ERVI .00LICENSED CONTRACTORS DECLARATIOuo 1 hereby affirm that 1 licensed under provisions ofCapter 9ISSUANCE DATE
n 1 N' ((commencing with Section
7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F y z Professions Cod and m icense is in full force an e f ❑ ❑
Z2
O w- License Ci Lia Number
Q YDate S/�Contractor -
¢ ¢ OWNER-BUILDER DECLARATION m BUILDING PERMIT
Is ¢ a u REFER TO ORD INFORMATION
E.
a, H whereby affirm that I am exempt from she Contractor's License MISC.- VALUATION S/PT6
u o Law for she following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 jow.
L- - Code:Any city or county which requires a permit to construct,alter,
N Y
improve,demolish,Or repair any structure,NCWre,prior to its Issomme,also ELED.CONTR. LIC.NO. - ELEC. / n �(/�
¢ 7 a o P IW.J•Uv
O u requires the applicant for such permit to file a signed statement that
TOTAL PERMIT TO
wm he is licensed pursuant to the provisions of she Contractor's License �.
F z a
Law(Chapter 9(commencing with Section 7000)of Division'Of the
i i c Business and Professions Code)or that he is exempt therefrom and OT3. PLUMBING PERMIT' ? ': `..FEE
It I- the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TYPE CONSTR.
d ; �$ by any applicant far a permit subjects the applicant to a civil penalty ALTER-DRAIN IEA.) 5.00
of not more than Ove hundred dollars($500).):
❑ 1,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 Dfl AINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of - -
property Who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 gD.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS EA.SYSTEM-I INC.4 OUTLETS 6.00
ments are not intended or offered for sale.If,however,the building
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 burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). I NDUSTR IAL 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 ASSESSORSPARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who build's or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ 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
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab C.).
'Policy No Company.
Q ❑ rtifird copy is hereby furnished. FIRE SPRINK ENERGY TQ4
ZZ Cerhtle cq�t• Is�le�wlt �7y --spec tion division. MISC.- REFERTOORD. Y❑ N❑ Y ❑ N❑
KOApplicant - 's _
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
UJ 1 COMPENSATION INSURANCE PLG.CONTR. LIC:NO. PLG. Y❑ N❑ Y E:] N❑
CL O (This section need not be completed if the permit is for one TOTAL
D Z hundred dollars(8100)or less.) ,-
U O 1 certify that in she performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} y 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 10MCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency far EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name - HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
do
0 I certify that I have read Ihis application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stem laws relating to building construction, and
hereby authorize representativesof this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cuperti against liabilities,judgments, costs and expenses which CONST.TAX
may " y ay ace see ag i st said City in cons see a of the PERMIT ISSUANCE 10.00
gra f penniL MECH.CONT. LIC.N0. MECH.
y PI- TOTAL TOTAL /
na of Applican Contractor Ute O