09735 (2) ..APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT FICATION PERMIT NUMBER
BrvI10 G AG APPLICATION & PERMIT O n
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
PLAN CHECK VALIDATION
" ��Y QTY. ELECTRIC PERMIT 'FEE
L - PHOEaE
oc
CO RACTOR'S
rvAM UTLETS-SWITCHES-RECEP 10.0011.00
"� (�' Cis. . LIGHTING FIXTURES 10.00/1.00
CONTRACTOR 5
ONessTOR's ]� /� APPLIANCES-RESIDENTIAL 0
1;�Jr y P-ON '�r/_ PANELS 10.00 DATE OF APPLICATION
OARCHITECT PANELS (OVER 200 AMP) 20,09 PLAN CHECK FEE P.O.NO.
ENGINEER
uc.No, SIGNS TRANS. 3.00
ARCHH.SS OR ENG. SPECIAL CIRCUIT - 5.00 PER T�(g}I TION
ZIPEMP.METER OR POL INS. 20,00
APoe ssTs MOTORSSEE FEE SCH. �p�V2�"���
g SERVICE CHAY61E 20.00 {r� L r
woo LICENSED CONTRACTORS DECLARATION TEMP.POL 30.00 City OB OWpUnO
a u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m G n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. P G MECH.
A4 Z Professions Code n m license is in full IF me rW f�g(.�n
z o w - License ClayS Lic.Numhcf I �l..u=
m Due 4 p &3 Contractor
¢ ¢ w u OWNER-BUILDER DECLARATION BUILDING ERMIT
F - MISC.— REFER TO ORD INFOR ATION -
w g ¢a I hereby affirm that 1 am exempt from the Contractor's License VALUATION S/FT.
.. o¢ Law for the following reason.(Sec.7031.5,Business and Professions
- PERMIT ISSUANCE 10.00
Code Any city or county which requires a permit m construct,alter,
re IS u ¢ 2 improve,demolish,or repair any structure,prior a its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o¢ requires the applicant for such permit to file a signed statement that TOTAL
e. w w lie is licensed pursuant to the provisions of the Contractor's License ERMIT TO
H 2 a Law(Chapter9(commencing with Sect ion 4000)of Division 3 of the -
i c Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT ' FEE'
¢ I- $ the basis for the alleged exemption.Any violation of Section 7031.5 ST RI S TYPE CONSTR.
a- - R by any applicant for a permit Subjects the applicant to s civil penalty
of not more than five hundred dollars(5500).): ALTER-DRAIN& VENT-WATER (EA.) 5,00 00
❑ 1,as owner the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
(S
their sole compensation,will the work,vol structure is not
intended or offered for sale (Sec. 7044, Business
and ProfessionsCOND. 5.00
Code:The Conrraator's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work 1 FIXTURES-PER TRAP 5.00 ,Cp SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own ennployees,Provided that such im Prove-
menus are not amended or offered for sale.If,however,thebuilding GAS-EA.SVSTEM-1 INCA OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or an. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUIL NO E
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND PB Oma
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(sec.7044,BusinessLAWN SPRINKLERS-1 INC 5 VB600 aSSESSo PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply V.B. .
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with it contnutor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec.—,B,&P.C.for this
reason WATER HEATER-1101110`110I 6.00 co
Owner Dale WATER SYSTEM 5.00 S.CO ACC.DATE ACC.FILE NO,
WORE:I:RS'COMPENSA7'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy Ihereof(Sec 3800,Lab.C.).
ooq
Policy Na Company y/�
O ❑ (7t'Iied copy is h eby fur 'sheat. ;
Z Z ❑ Crti d, cop is rled tltl Ole ily inspeclinn-divi5inn. FIRE SPRINK ENERGY T 24
~ OAppli�`nT. -�E ,yy� MISC.- REFER TO ORD. Y E] N 0 Y [D N�
PERMIT ISSUANCE 10.00
R — IPICAMPHNSAIilON INS FROM WORKERS' FLOODZONE A.L.U.C.
W COMPENSATION INSURANCE
PLG.CONTR. - LIC.NO. PLG.
D' O (This section need not be completed if the permit is for one TOTAL , Y M N Y [] N
D Z hundred dollars IS 100)or less.) -
U O 1 certify that in the performance of the work for which this per- CITY. 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 Workers'Compensation Laws of California.
IS. Dmc Applicant BUILDING
} e-7 NOTIC17 TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECN. 5.00
h-. ? 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 of this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.0 ,
CONSTRUCTION LENDING AGENCY AIRHANDLING UNITIOVER 10=C.F. .00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUC 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Ctv.CJ. HEATING UNIT(TO 100 B.T.U.) g.00
Lender's Name HEATING UNIT(OV 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATIO AN (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- (3 H.P,or 100,000 B.T.U.) 6.00
hereby authorize mpresentatives of this city to enter upon the gOIL -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 C.- REFER TO ORD.
Cu erlino against liabilities, "udgments, costs and expenses which PERMIT ISSUANCE 10.001CONST.TAX
ma in an
y way accrue a nit said City in con qucnce of the
grant gof[ permit -- M CH.CONT. LIC.NO, MECH.
TOTAL TOTAL /
Igm arc of Applicant/ ontiamor Date
' OFFICE COPY