6110 4PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
BUILDING
PDDRE55
O BUILDING - ELECTRICAL-PLUMBING-MECHANICAL6110
OWNER' PLAN CH E LIDATION
"AME , OTY. ELECTRIC PERMIT FEE P
ON 7
CONTRACTOR EG-SWITCHES-RECEP 5.00/1.00
rL gut NNS FIXTURES 5.00/1.00UTLT
CONTRACTORS
APPLIANCES . City of Cpt
PONEPANELS DATE OF APPLICATIONAR IAIZA
5.00
PLAN CHECK FEE P.C.NO.
ARCHITECT 9s�oy3 SIGNS 6.00
OR
ENGINEER 7
uc.No. SIGNS TRANS. 3.00
PERMIT VALIDATION
ARCH.
DD'Ess E "c' y: - SPECIAL CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 15.00 �� �
APPLICANT'S /
ADDRESS •- MOTORS SEE FEE SCH.
LEI
SERVICE CHANGE 10.00
o a LIU.NSED CON 1 RACTORS DECLARATION
ARATION
+q�
r.1 ¢mby aft�ms(hal 1 am bcinscd under piavrs o"svf s;mprci.9 = :_ __-__ .- _ _ -- _".'ISSUANCE DATE
H < n ( ommen mg will Section 7000) (Dr ISI m 3 oyfd t�hef�Bul/siness and BL `ELECT"`^PLG.-� ^MECH..
zz ,D 14ut 'i ns CnJ A�yy license is full in /O f// O ❑ O
z o F 'License ssi7_L L' Nwnbcr OJtJ �/
¢ y W �7 L UILDIRM PERMIT
¢ ¢ w u
OWNER-BUILDER DECLARA'RON - INFORMATION
wO a h I hereb ai irm that I 'm exam I Innn the Contractor's License MISC.- REFER TO ORD
3 y . IL P VALUATION $/FT.
F LL o a Law for the following reason (Sec.7031.5.B,RiRV...md Professions PERMIT ISSUANCE 6.00
Code:Any city or county wh eprnmuires z permit to construct,alter. /�-�
7
p/Q
¢ ¢ ¢ 0• improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /U (�A
y' O¢ rl•Qmres the applll'am I Vr such permit t0 file a signed Stalenlenl that TOTAL PERMIT TO
au mhe is licensed pursuant to the provisions of the Contractors License
g, z¢ Law(Chapter 9(commencingwith Section 7000)of Division 3 of lire _
Business and Prolusions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ moo rbc basis for the allcgcd exanption.Any v iol.rior ofSecticn 7031.5 STORIES TYPE CONSTR,
ate _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
/
of not more than five hundred doll...155000.1:
❑ L as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
them sale compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'The Contractor's License Law docs not apply to an owner of
proparty who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mens arc not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or cliprovenmnt is sold within one year o1'completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that Ise did not build or int- E IND CON PR Omer
prove for Purpose of,&,), INDUSTRIAL WASTE INTER. 20.00
❑ 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.O. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's Liccnw Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1,00
contracts for such PmjcUs with a contruetorfo licensed pursuant to
On,Contractor's Liccnw Law. SEWER-SANITARY-STORM EA.200([/8.00 i TRACT NO. PARCEL NO.
❑ I am exempt under Sri. ' .B.&P.C..lir l his WATER HEATER W/VENT 4.00
myon
D
C1 Aate WATER SYSTEM 4.00 / ACC.DATE ACC.FILE NO.
'R �"IVFf is :Tl On niIAT10N WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a cetlificam nl consent to s<IGinnve' ZONING
nr a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof 3800,Lab C14&&V
1.���/� ���
Policy Nu. Companyl�u]LS.FiAI
Q ❑ Cernbed copy is hereby furnished. FIRE SPRINK ENERGY T24
z ZCertiled copy is filed with the city inspection division.
O picarl MISC- REFER TO ORD. Y ❑ N❑ v ❑ N❑
CC LO ) Cl?Rl'114CA'1'1-01'IiX1iMPTION PROM WORKIiRS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
LU 1 CO.MPBNSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
d Y❑ N E] Y ❑ N❑
O (This secti6r, recd not be completed if the permit is for one TOTAL
::) Z hundred dollars IS 100) r less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
EL I- ntit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers Compensation Laws of Calilnnia.
ED Dow - Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} 0- NO110E 'f0 APPLICANT': If,ufwr making this Certificate of 17
F Z emption,you should become subject to tire Workers'Compensation APPLIANCE 4.00 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) 3.00
CONST RUCFION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE Pz5z
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance u1Oo work for which this permit is issued(Sec. MICROFILM
3097,GIm.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Loader's Name
Lenders Name ss NHEATI NG U )7
N IT 100,000 B.T.U. .50 ELECTRIC
1 certify(list I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances ..it state laws relating to building construcRon. and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter (mon the BOILER-COMP (Over 100p00BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
CuperUrus against liabilities,judgments, cost and expenses which CONST.TAX
may i>.a way :¢cnf 'Isaias(said City in wnscqucnce of the PERMIT ISSUANCE 3.00
gr' mg o Tri'pent H. - x� MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
1L
'Slgnat�o(Applicant/Contracmr Date Z
INSPECTOR COPY