8418 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION
PERMIT NUMBER
BUILDING �O�o�� APPLICATION & PERMIT
ADDRESS
/(� aLfjn/�( 411&- BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
_ A41 8
OWrvER'S ` PLAN CHECK VALIDATION
NAME NuJ R+I) !3 L A PIER t I O QTY. ELECTRIC PERMIT FEE 'y-P
/I�/v sorvE GYLy
CONTRACTOR'$ //-i
NAME C I � yyp Q/1�G /t5t !4C UTLETS-SWITCHES-RECEP 10.00/1.00 U_.1
J IC 1� 1 1� uc.NfoY. LIGHTING FIXTURES 70.00/1.00
CONTRACTOR"5
ADOREss 5AN s�oS= G PPLIANCES-RESIDENTIAL 4.00
p 63 2 Q Ho-E PANELS 10,00 DATE OF APPLICATION
ORRCRI LT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
UC.NO. ti SIGNS TRANS. 3.00
ARCW OR ENG. y SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS LIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
,00 LICI:NSI:I)CONTRACTORS DI?CLARATION TEMP.POLE 30.00
2 i w I*hereby affirm that I no licensed under provisions of Chapter9 ISSUANCE DATE
,o a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
`I, w z Professions Code,and my license is in full force and effect./�
z o w - License Clies C, 'Z q Lic.N'umbcr-. -1/!AW �
9 ao F o Date Contractor G r.�/"^ /
.ay5 /, d� BUILDING PERMIT
,pp-��yyIS" .
¢ ¢ a OWN17 R-BUI LDI:R DECLA BA'PION•GCE�$'t
o a v INFORMATION
w 3 ¢ I hereby itHinn that I am exempt from the Con tractor's License MISC.- REFER TO ORD
VALUATION $/FT.
r ,moa Law for the following rcuson.ISec.7031.5,liusincss:md Professions PERMIT ISSUANCE 10.00
_ Code:Any city or countywhichre,puresapemril reconstruct,alter, L�
¢ 2 a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. / t0
D a .quires the applicant for such permit to file a signed smtemcnt that TOTAL PERMIT TO
w he is licensed pursuant to the provisions of the Courramor's License
eu Law(Chapter 9(Commencing with Section 7000)of Division 3 ofihe S7 �.Z}-I N� �4L�
4 o Business and Professions Code)or that he is exempt Derefrom Bnd QTY. PLUMBING PERMIT FEE 7XC`
¢ ro the basis for thealleged exemption.Any violation of Section7031.5 STORIES TYPE CONSTR.
IT 3 °�' by Bay applicant for a permit subjects the applicant toB civil penalty
of not more than five hundred dollars($500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 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 Get
intended or offered for sale (Sec. 7044, Business and.Peofessions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractors License Law does not apply to an owner of
property who builds Or improve,thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
�` .cuts are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-11INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, - . - . .
the owner- GAS EASYSTEM OVER 4 (EA ) 200 BUILDING USE
builder will[lave the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000
❑ I,as owner of the property,am exclusively contracting with . ❑ 0 0 0 0
licensed contractors to construct time project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law dues nut 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 eontracoms)licensed pursuant to SEWER-SAN EA.2001[/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&1'.C.for this WATER HEATER W/VENT 6.00 '
reason
Owner /Date WATER SYSTEM 5.00 ACC.DATE ACO FI LE1010.
tVORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby infirm that 1 have ucertificate of co novel 10 Self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Compensation Insuraho, a certified
copy it f c }8,O4b L:�,Q� '4
t Policy o p RIg
0 ❑ CcHilied copy is hereby finished' FIRE SPRINK ENERGY,T 24
z_Z Cl Certified copy fled wi Tile city inspection division.
O�- Applicants/��(r.y? y_�_Pc!o a;_C � MISC.- REFER TO ORD. Y C] N0 Y [:] NE
~ T ran ISSUANCE 10.00
� - CERTIFICATERTCERTIFICATEOP RXISMfiION FROM WORKERS' PERMIT FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG, y� ru� v � N�
CL Z (This section need not be completed if the permit is for one TOTAL
hundred dollars($100)or less.)
U O 1 certify that in the perfmmuiee of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shell not employ any person in any(Brunei so as b
U- becomm subject to the Workm,'Compensation Laws of California.
O w
Dille ApphUnt BUILDING �`
a ALTER OR ADD TO MECH. 5.00 e�
} N NOTICE '10 APPLICANT': If,after oinking this Certificate of lix-
F Z enmtion,you should become subject to the Wurker-a'C(,n.pensation - APPLIANCE 5.00 PLAN CHECK
provisions of file Labor Code, you must forthwilh con.ply with -
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.W 4.00 FEE I
CONS'fRUC'I']ON LISNDING AGENCY AIR HANDLING UNIT(OVER 10DMC.F.M.) 6.00 SEISMIC FEE a•'�
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. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
\ Lender's Name
Lender's AddreHEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ss
I certify that l have read this application and state that fire above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 1000008.T.U.) 6.00 PLUMBING
1 ordinances and state laws relating to building construction, and ,
hereby authorize representatives of this city to enter upon the
above mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU(SEE FEE SCH. MECHANICAL
-
(We) agree to save, indenmify and keep harmless the City of MISC.- I,: REFER TO ORD.
Ceperino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
ay
mal an By accrue against said City in consc9ucnce of the
gee tin Is penmL MECH.CONT. LIC.NO. MECH,
- TOTAL TOTAL7`6
i s e A i of/Contractor tc 4 �.
INSPECTOR COPY