8691APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
8691
BUILDING
ADDRESS
Aum 00
0 'S
PLAN CHECK VALIDATION
NAME_
QTY. ELECTRIC PERMIT FEE
ONE
TRACTONAME Rs
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
sec. No. L
�15I[TFIACfVPFS ADDRESSPPLIANCES
- RESIDENTIAL 4.00
PANELS 10.00
491RCT &eMa op le PHONE
DATE OF APPLICATION
OP
PANELS 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
ENGINEEP
tt"6C. No.
SIGNS TRANS. 3.00
ADA.DRESS E o
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
.2691)1 Ake,
TEMP. METER OR POLE INS. 20.00ADD/��
L cA s
NE55
MOTORS SEE FEE SCH.
SERVICECHANGE 20.00
LICIiNSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter
(commencing will, Section 7000) of Division 3 of the Business and
Pir fessions Code, I y license is in full force and e
License Class _(�jn� Lia Number
ISSUANCE DATE
{
BLDG.
ELECT.
PLG. MECH.
❑
Date Contractor
Z�/ffi6`N'I.R-BUILDER DECLA TW --
1 hereby coi 1 am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5. Business and Professions
Code: Any city or county which requires a permit to construct, alter.
improve. demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9(commencing with Section 7000) of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and
BUILDING PERMIT
INFORMATION
.-
MISC. REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTR. LIC, NO.
ELEC.
TOTAL
PERMIT TO
••��
yC�"/uL.T o1/vJ /N id'L�
QTY. PLUMBING PERMIT FEE
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penally
of not mune than live hundred dollars (S500).):
ALTER -DRAIN -WATER (EA.); 5:00
CII, as owner of the property, or my employee with wages as
sole cumpan'ution, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
intended or offered for sale (Sec. 7044,. Business and Professions
Core: 'I'lm Contracwr's License Law does not apply to an uwner, of
property who builds Or hnproves thereon, and who does Such work
h imsullor Ilimugh his own employees, provided that such improvr
.rents are not intended proffered for sale. If. however, the in bding
F IXTUR ES - PER TRAP 5.00
50. FT, FLOOR AREA
TOTAL ACREAGE
GAS-EA.SVSTEM-I INC-40UTLETS 6.00
or int Rowemmnt is sold within one year of completion, the owner-
builder will have file burden of proving that he did not build or im-
prove for purpose of sale.).RES
❑ I, as owner of the property, am exclusively contracting with,
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
IND CON Pa Other
El 0 ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed cmu... tors to construct lite project (Sec. 7044, Business
and Professions Code: 1'he Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for suet, projects with a contract.oO hcensed pursuant m
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C. for Iris
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC.OATE
ACE. FILE NO.
WATER TREATING EQUIP. 5.00
W'ORKI:RS'COMPENSAT'ION DECLARATION
1 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 thereof (Sec. 3800, Li b.C.).
Policy No Company -T -
❑ Certified copy is hereby furnsl..w('4�yG��,�P
.0 oCuNified copy i filed with the city In,pec'flmisdi ft,
Int
MISC. - REFER TO ORD.
FIRE SPRINK
y ❑ N
ENERGY T24
y ❑ N[]
CER' I' I FICA'11:01liXIiM TI Ou�WORRERS,
PERMIT ISSUANCE 10.00
FLOOD ZONE
at,. U.C.
C04ENSA I' ION INSURANCE
section aced not he completed if tie permit is for one
PLG.CONTR. LIC. NO.
PLG.
TOTAL
y� N�
Y� NE]1'I'hls
hundred dollars (8100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
A040!Q
T
become subject to the Workers' Compensation Laws of California.
Date Applicant
'1'O
. .
ALTER OR ADD TO MECH. 500
NOTICE APPLICANI: If, after making this Certificate of Ex
motion, you should become subject to the Workers' Compensation
APPLIANCE 5.00
PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10)000C.F.M,) 4.00
AIR HANDLING UNIT (OVER 10,1000C.F.M.) 6.00
SEISMIC FEE
/O
ciz
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
tile 3097 �Civrcince of the work for which this permit is issued (Sec
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's e
amN
Lender's Names
HEATING UNIT (OV ER 100,000 B.T.U.)9.50
ELECTRIC
I certify that l have read this application and state that lire above
VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
ordinances and stale laws relating to building construction, anti
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
gQILER-COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hefchy authorize representatives of this city to enter upon the
above-mentioned property I., inspection purposes.
misc.- REFER TO ORD.
(We) agtne to soul:, indemnify and keep harmless the City of
Cuperlinu against liabilities, judgments, costs and expenses which
may in any wary uwner against said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
granting of this permit.
�((j 5�j/��
NisK,, r A j ont sec r Date
MECH. CONT. LIC. NO.
TOTAL
TOTAL
��, Q
INSPECTOR COPY