7160 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
+ BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
BUILDING
�I,�! ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7160 .
OWNER'S • - - - - PLAN CHECK VALIDATION
$'C "A°�E♦ 2 /'!/ QTY. ELECTRIC PERMIT FEE
CY',4rL` r I11T/+V•�=/C VHONE 1 z� % /Y L
CONTRACTOR UTLETS-SWITCHES-RECEP 5.00/1.00
_ '� NAME,1z4-/3 L9ii/r /;/ZMt)7C AUA IiIC.NoA -jf l= LIGHTING FIXTURES - 5.00/1.00
CONTRACTOR'SA� S / - PPLIANCES-RESIDENTIAL 4.00
7C LJrli$YP.N vp •s( ROPE2 -7--.0)l PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
nooaesR ENG. - SPECIALCIRCUIT 5.00 PERMIT VALIDATION
zip TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS1 <1115
SERVICE CHANGE 10.00
wo o LICENSED CONTRACTORS DECLARATION
¢ u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
yc N 1 n n ing with Section 7000)of U vision 3 of the Business and " BLDG. ELECT. PLG. MECH.
F Nr I nN 'I s Cody my¢ens s"If II for, eqd 4 t •❑ - ❑- ❑ ❑
C o F.�i L, t' ('lass J Cc Nunb.r • `r}.
C to D Dd4-1 V Contractor
H ✓ BUILDING PERMIT
¢ ¢w OWNER-BUILDER DECLARATION INFORMATION
X o 1 hereby affirm that I am exempt from the Contaclor's License MISC.- REFER TO ORD
I y ION $/FT.
F u o a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires permit to construct.alter, CQ
rt ¢a 0O improve.demolish,apFepair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ,
ELEC.
a
requires the applicant for such permit to file a signed statement that TOTAL V PERMIT TO
K
w he is licensed pursuant to the provisions of ore Contractor's License ^,I
Law(Chapter 9(commencing with Section 7000)of Division 3 of the �PAIK (NA'TE''Q�9jy
a Business and Professions Code)or that he isexcerpt therefrom and QTY. PLUMBING PERMIT FEE
P ¢ O 1
¢ r o the basis for the alleged exemption.Any violation ofSection 7031.5 .i1 r TI S TYPE CONSTR.
ate _ by.aay'applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER MA.) 4.00
of notmore than live hundred dollars(8500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
Their sole caripimori.n,will do the work,and flit trucmre is not _
intended nr offered for sale(Sec. 7044, Bosun... and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'Phe Contractor's License Law does not apply to an owner of
s property who builds or improves thereon,and who does such work FIXTURES-PER TRAP • 4.00 SU FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- - '
mmor
es am not intended offered for sale If,however,the building GAS-EA.SYSTEM'-1 INCA OUTLETS 4,00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA ) 1:00 euILDING USE.
builder will have the burden of proving that hnt- . .
e did not build or i - RES IND CON PB Omer
prove for purpose of.lk L INDUSTRIAL WASTE INTER. 20.00
❑ 1;as owner of the property,am exclusively contracting with _ ❑ . ❑ ❑ ❑ ❑
licensed contractors to construct Hie project(See.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cade:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
convects for such projects with a comrumods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/6.00 'TRACT NO. PARCEL NO.
❑ l am exempt racer Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
on
Owocr Dam WATER SYSTEM 4.00 - - ACC.DATE ACC.FILE NO.
WORK IiRS'COMP[NSA'IION DECLARA'f ION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsenl toscll'-insure, ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thcrapj c j800,Lab.C.). �n �• vp rj
I'nlicyN BSmpany
O' ❑ Certifiedcepy is hereby furnished. - FIRE SPRINK ENERGY T-24
Z Z ❑ Certified Fµpy/t iz Qled ith the city inspection division: MISC.- REFER TO ORD. y❑ N❑ y ❑ N❑
Q Applicant . l-sF
h CERTIFICATE OF Ii X�'ION 17ROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.UX.
LUO COMPENSATION INSURANCE; PLG.CONTR. UC.NO. PLG. Y❑ NE] v ❑ N
(This section need not be comldeted if the pentiit is for one TOTAL
2 hundred dollars($100)or IessJ
I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
mit is issued, I shallnot employ any person in any Limner so as to
• U W become subject to the Workers'Compensation Laws of California. .BUILDING q
a U:uu Applicant - ALTER_OR ADD;TO MECH. 4.00
} to NOT ICF '1;0 APPLICANT: If,alter making this Certificate of Ex- _
(_ 2 emption,you should become subject to the WorkerE Compensation APPLIANCE .4.00 PLAN.CHECK
provisions of the Labor Code, you nuts) forthwith comply with FEE
U such provisionsonthis permit shall bedeemed revoked AIR HANDLING'UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE .f0
I hereby affirm that there is a construction lending agency for EXHAUST HOOD,(WITH DUCT) 2.00
the perhormm.aa of the work for which this permit is issued(Sec. MICROFILM
3097,Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name - - HEATI NG UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lence,s Address
I certify hat I have read this application and state that The above VENTILATION FAN (SINGLE) 3.00
PLUMBING
information is correct.'[agree to comply with all city and county
ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U) 4.00
hereby authentic representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE,FEE SCH. .MECHANICAL
above-olentioned property for inspection purposes.
(We) agree to save, indemnify and keep honnlms the City of MISC.- REFER TO ORD.
Capertinu against liabilities,judgments costs and expenses which CONST.TAX
may In ate' way ac n r again?said City is n. Ise nee or.the PERMIT ISSUANCE_ 3.00
gr ltDm�yy'1 ��It MECH.CONT. LIC.NO. MECH. `
E R.•ye) ���:r1if TOTAL TOTAL oZ y
'i alurc of Applicant Contractor Date
OFFICE COPY '