C8783 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
T rADDisE o�p JEJj � 0 APPLICATION & PERMIT
Fit
BUILDING-ELECTRICA L-PLUMB ING-MECHANI FAL 8783
WNER PLAN CHECK VALIDATION
NAME OTY, ELECTRIC PERMIT FEE
FACTOR'S
/ ONE
� NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
y Crons ADDRESS LIC.NO. LIGHTING FIXTURES 10.00/1.00
PPLIANCES-RESIDENTIAL 4.00
, DDRE5
RC
PHONE PANELS 10.00 DATE OF APPLICATION
i
DR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH Ess clue. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION,
.1 ZIP EMP.METER OR POLE INS. 20.00
i APPLICANTS MOTORS SEE FEE SCH.
ADO RE SS
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00At o
vI hereby affirm that I am licensed under provisions of Chaptnr 9 ISSUANCE DATE
m G% (commencing with Section 7000)Of Division 3 oit f the Business and BLOC. ELECT. PLG. MECH.
H m z Penrofessions Cod•,and my license is in full(or< ueffecl. ❑ ❑ ❑ ❑
z o w - Licse Class ji,c s Lic.Number d7�
om IJum Contractor '� -��-
a m f D j BUILDING PERMIT
az cE
o u o OWNER-BUILDER DECLARATION INFORMATION
w g u HI hereby affirm that I am exempt from the Contractor's License MISC.- REFER-TO ORD
VALUATION----
FUOJ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 1000
Code:Any city or county which requires a permit to construct,alter.
QQ ¢ p ImpPoVC,de1n011511,Or repair any structure,p110!to IIS ISSDanee,aISO ELEC.CONTR. LIC.NO. ELEC.
C LL T TO
requires the applicant for such permit to file a signed statement that TOTAL v
a w m he is licensed pursuam to the provisions of the Contractor's License PERMI
Hza Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE V �V
CC r$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n . by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER MA.) 5.00 1
of not more than five hundred dollars 1 S50D.1:
❑ 1,as owner of Ole properly,or my employees.fit,wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
Darin
sole com penmtion,will do the work,and the structure is not
'intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 5.00 SO.FT FLOOR AREA TOTAL ACREAGE
• merits himselforthrough his own employees.provided that such improve- GAS-EA.SYSTEM-1 INC. OUTLETS 6:00
mems are not intended or offered for sale.Ic however the building _ _
or improvement is sold within one year of hacompletion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ Q ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.8. 6.00 ASSESSORS PARCE L NO.
and Professions code: no,Contractor's License Law does not apply
to ao owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a con(mctor(s)licensed pursuant In
the Contractor's License Law. f SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ taro exempt under Sec. ,B.&P.C.lin this WATER HEATER W/VENT 6.00
reason
Owner /r Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERStCOMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm thork s'Compensation a certificate of consent or selfeffifi e.
or a cerrificare of H'orkc Ledi'CInsurance,or a eerlifittl ZONING ENG.SITE NO.
copy thereof(See 3800,La9.C:).
Policy No. Company
O ❑ C• .�rnpy in lmrchy funlishctl. FIRE SPRINK ENERGY T-24
Z Z Crlllll'It Opy•IY II L'd WIIt, the Llly mpeL'lio" dlvia,o,.
p , pplican J 5"6.,
" A MISC.- REFER TO ORD. v N v ❑ N�
~ w+ -��- r FROM i_�- PERMIT ISSUANCE 10.00
LU - CIiRT1IlCATIIPI:NSA[ON INSUROh1WORKIiRS' FLOOD ZONE A.L.u.C.
W C011PEt be completed
INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y❑ N�
Z (This section need not he complead if the permit is for one TOTAL
hu1 cert dollars(S 1 the)performance
LL O 1 certify that h the to employ
an of the work for which this pct- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
� F mit is issued,1 shall not employ any person in any manner so a to 1
(D become subject to the Workers Compensation Laws of California.
ED Date Applicant ALTER OR ADD TO MECH. 5.001BUILDING �. „(71
} W NOTICE TO APPLICANT': If,after making this Certificate of Ex-
♦- Z camption,you should.become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply will FEE q UZ
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000OF.M.) 4.00 a r
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE•
I hereby affirm that thert\is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work I'or which this permit is issued(Sec. MICROFILM
3097,Cie.C.). H EATING UN IT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
inlbnomiml n ullater. I agree to comply with all city and county PLUMBING
ink)rnialm and state laws relating to building consvaclion, and BOILER-COMP(3 H.P.or 100,0008.T.U.) 6.00
hereby auOloriu representatives of this city to enicr upon the BOILER-COMP (Over 100,000'BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER`TO.OR D:
Cup o against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
m- i any way accrue against said City in consequence of the
Tani g of t is permit MECH.CONT. LIG NO. MECH. -
TOTAL TOTAL 2
n
i natme of Applictit/ o tr cror L) to ��..
INSPECTOR COPY ,
t