C9317 APPLICANT T /FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION i - PERMIT NUMBER
ABUILDING
DDRESS �,- APPLICATION & PERMIT 8317
ADDRESS
.Y BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
.012 - AN CHECK VALIDATION
NAME t QTY. ELECTRIC PERMIT FEE ry�(j
_ PIED El y U T
NAME DRs IS UTLETS-SWITCHES-RECEP 10:00/1.00 /�
-T( .tio, LIGHTING FIXTURES 1-QJ)0/1.00 l (N37e11414ef
dooeess 5$; APPLIANCES-RESIDENTIAL 4.00 S
_'1C PHONE PANELS 10.06 DATE OF APPLICATION ?
onnVIRCHIT . "Ar PANELS (OVER 200 AMPI 20,00 PLAN CHECK FEE P.C.NO.•
E NGINEEn
uc.No. SIGNS TRANS. 3.00 Eq.
AARCFH poaess ENG' SPECIAL CIRCUIT 5.00 PER MIT VALIDATION e
7r ZIP TEMP.METER OR POLE INS. 20.00 ,D
ADDRESSPPLICA pAar$
AMOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 G
w 0 o LICENSED CONTRACTORS DISC LARATION TEMP.POLE 30.00,
U U 19�[
a i w. I hereby affirm that I:um licensed undrr fmUVigm1S of Chapter 9 - ISSUANCE DATE
a w (commencing with Section 7000)of Division 3 of the Business and D (� CT. PLG. MECH.
H z Professions Code,and my license is in full force and effect.
Z O H - License Class- Lie.Number 6 5 39 ❑ ❑
-o -F D Date g,,I -ContractorEX'tE-
.a m EBUI ENG PERMIT
a w u t ' b�'DI:�IaECSQ ^'i �A I FORMATION'S
w ; LL H I hereby affirm that I um exempt from the Conlmctor's License MISC.- REFER TO ORD VALUATION
H ac D¢ Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE S/FT.
0 Code:Any cityorcounty whiehrequiresapermittoconstru",alter.
m p p' y riot to its issuance,also ELEC.CON ER. LIC.NO. as U(��
A,
< 0 improve,demolish.or repair an structure,p ELEC. /
¢ requires the applicant for such permit to file a signed statement that TOTAL - PERMIT TO
a w m U. he is licensed pursuant to the provisions of to Contractor's License
FZ Law(Chapter 9(commencing with Section 7000)ot'Division 3 of the
E EE o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
EE E_ a the basis for the alleged exemption.Any violation of Section 7031.5. ST IETYPE CONSTR.
aim by any applicant for a permit subjects the applicant toa civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
O 1,as owner of she property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,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 Thr Commetor's Licmise Law does not apply to an owner of
properly who builds Or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO,FT,FLOOR AREA TOTAL ACREAGE
• himself re through his own employees. le.If.cd that such improve.
mmsel
himself
not Intended one ered foremployees,
sale.If. thathowever,thebuildingGAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, - . -OVER 4 (EA.) 2.00 tire owner- GAS EASYSTEM
builder will have the burden of proving that he did not build or in,- BUILDING USE
prove for purpose o(hals.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of tire property,an exclusively contracting with I ❑ ❑ ❑ ❑
licensed contractors to construel the Project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who huilds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects will a contraoods)licensed pursuant to
the Cons moor's License is w. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Scc. .B.&P.C.for This WATER HEATER W/VENT 6.00
reason
Owner Dare WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORKI'RS'COMPI:NSA1'[ON DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
T Policy No. Company
O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z/ ❑'Certified copy is filed with the city inspection division. MISC. REFER TO ORD.
O Applicant Y ❑ NE] Y CJ N[:]
� N! CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00
FLOOD ZONE A.L.0.C.
W > COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLG. YE] NC] Y'❑ NEI
Z (This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT, FEE FEE SUMMARY -
LL F Got is issued,I Shall not employ any person in any mmmnerso as to
U - become subject 1.the Workers'
} mmenasuao wl of Califomiu.
Ed Applicant
ALTER OR ADD TO MECH. 5.00 BUILDING
w aTIICAN1DOSa
u e o -
FZ emption,you should become subject to the Worker:Compens ion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply will FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE sip
I hereby affirm that fere is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of rte work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT 100,000 B.T.U.)9.50 �f
Lenders Address ELECTRIC
I «.lily that l have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
nomination is correct. I agree to comply with"I city and county PLUMBING
�. ordinances and state laws relating to building construction, and BOILER-COMP(2
H.P.Dr100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon she BM
above mentioned property for inspection monoR-COMP (Over 100,000 BTU)SEE FEE SCH. / MECHANICAL
xs.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertt o against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST_TAX
may i any way accrue against said City in cunsequence of the
gr It of this pcnnl MECH,CONT. LIC.NO. MECH.
- TOTAL TOTAL
�7� 0
ign u p li to s
INSPECTOR COPY
I