8723 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
/x\ BUILDING APPLICATION & PERMIT g 723
ADDORESS D
LDING-ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
7 NAME �/57 p( y OTY. ELECTRIC PERMIT FEE
p o
\ /
CONTRACTOR'S
NAMEUTLETS-SWITCHES-RECEP 10.00/1.00
LIC,NO, LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO. SIGNS TRANS. 3.00 '
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.ADDRESS SERVICE CHANGE 20.00Jt:� alq
lkf
D O o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
r
a uI hereby affirin that I am licensed under provisions ol'Chapter 9 D ISSUANCE DATE
h G a_ (commencingwith Section 7000)of Division 3 of the Business and B ELECT. PLG. MECH.
H w z Professions Code,and my license is in full force and effect. �� ❑ ❑
z o m - License ClassLic.Number
-
PO Z F D Date-Contractor 1'
BUILDING PERMIT
¢ ¢ w¢ OWNER-BUILDER DECLARATION
o A " MISC.- REFER TO ORD RMATION
R:
; LL N 1 hereby affirm that 1 am exempt from the Contractor's License
.L vi Law for the following reason. 7031.5.BirimesSiod Professions pERM1T ISSUANCE 10.00 AWATION /FT.
L" - 0 Code:Any city or county which reyuircsu permit o construct,alter. a
ce ¢ Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. yr
- DLL requires the applicant for such permit to lila a signed statement ilia, TOTAL PERMIT TO
A w m he is licensed pursuant to the provisions of the Contractor's License
ar Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe % ol J.�')O
tl
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ✓v 1 s
2 H m the hasis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aLa te_ by Boy more
fora permit subjects $5000.licannoBcivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not marc than five hundred dollars(my ):
❑ ole owner n of theanon. ill do the work,
employees dt whh re is not
BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole r offered
compensation.will(S the work,and the structure Is Rol
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The who
or License Law does not apply to an owner of
property Wha bndd5 Or improves,hes,pr,andel tadoes t such improve.
work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himselforthrough his own employees,providedthatsuch improve GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
mens are not intended w offered for sale.If,however,the building
or im rovement is sold within one year of Completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
build r will have the burden of proving that he did not build or im. BUILOIN uSE
pr) •for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND PB Omar
J I,as owner of,he pro petty,ant exclusively contracting with ❑ ❑ ❑ ❑
1'(ease contractors to construct the pmfeel(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSO SPARCEL NO.
nd Professions Code:The Contractor's License Law does not apply
to an owner 'property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 1EA.) 1.00
contracts to s ch projects I u tmmoR s)licensed pursuant to
the Contra o s icense SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Ia ptl .B.&PC or"
s WATER HEATER W/VENT 6.00
/ reason C -ec.
own Dal WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPIi A70 CLARA'f N WATER TREATING EQUIP. 5.00
I hereby a((irm tlmt I h e a ce ificute of consem........
o scl(-insure, ZONING
or
ce"fieale of Workers cnsation Insurance,or a evi-hiixW ENG.SITE NO.
copy thereof(5ec.3800,Lab.C.).
Policy Na. Company
0 ❑ CerlifieJeopyisherebyfumished. FIRESPRINK ENERGY T 24
Z_ 2 ❑ Certified copy is tried with ,he City inspection division. MISC.- REFER TO ORD.
Q Applicant V [:] N❑ Y ❑ NE]
11
~ rn PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.D.C.
LUCERTII'ICATEPE EXEMPTIONAINNS FROM WORKERS'
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Q. Q ('Phis section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
D Z hundred dollars IS 100)or less)
U O I certify that in,he performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall no,employ any person in any manner so as to
become subject,o ilia Workers'Compensation Laws of California.
�)
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING aD V
} N NOTICE TO APPLICANT: If,after making ibis Certificate of Ex-
? 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
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M,) 4.00
CONSTRUCT 00
ION LENDING AGENCY AIR HANDLING UNIT(OVER 10pC.EM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 s
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. I HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's AddreH EATING UNIT IOV ER 100,000 B.T.U.)9.50 ELECTRIC
ss
I Certify nou l haverend thisapplication and state,hut theabove - VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby authorite representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-me med property for inspection purposes.
(We) g e It save, e y and keep harmless the City of MISC.- REFER TO ORD.
Cuperti 0 ga" It lin es gments,costs and expenses which CONST.TAX
may a y ay a st said City in couseq ecce the PERMIT ISSUANCE 1000
gran a MECH.CONT. LIC.NO. MECH.
01 9 TOTALfir TOTAL
�/7 g a re of A cant/Con ct r Date
//l/ OFFICE COPY