5755 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMSER
EMIL TNG APPLICATION & PERMIT
Aon R1.
1 110,5% zmillr �T r BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 5755
u OWNER'S PLAN CHECK VALIDATION
OTV. ELECTRIC PERMIT FEE
T EG7RS �QjlJS�N/cnoNE
CONTRACTORS CI45YOUTLETS-SWITCHES-RECEP 5.00/1.00 S_
NAM
�e LIC.NO. ,��aIII LIGHTING FIXTURES 5.00/1.00 S -'
DDRESS SCTDRs
APPLIANCES-RESIDENTIAL 4.00
ADDRES �J/�
-///E moo, PHONE ��xJ PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.rvo. SIGNS TRANS. 3.00
ADD ESS ENa SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
APPLICANT S
PPLICSMOTORS SEE FEE SCH. S O
ADDRESS
f - SERVICE CHANGE 10.00
o oLICENSED CON'T'RACTORS DECLARATION
Q U U I hemhy a(6rm 0nat 1 am licensed under provisions of Chapter 9 .ISSUANCE DATE
y a m (conlmenemg with Section 7000)of Division 3 of the Business anJ BLDG. ELECT. PLG. MECH.
r N z Professions Cod", try,[*crnse is in full fur ffrrls-/
z v,In - License ClasI.R.Number /t 6 El ❑ ❑
O w H o Date Contratlar
.-¢ M s - 1• BUILDING PERMIT
5 a up+-u OWNER-BUILDER DECLARATION INFORMATION
soA r^. MISC- REFER TO ORD
w 3 1 f r ilia
noire that I am exec.7031.5 the Contractor's is L,sions
Fuo¢ Law for tllC following reason.(Sec.7071.5.Business Professions PERMIT ISSUANCE 6.00 O` VALUATION $/FT.
_ 0 Coda:Any city or-county whiehreyuiresapermittoconstrucLniteq
- a a, Q Q improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR. LIC.NO. ELEC. Q
0 LL requires the applicant for such penult to file a signed statement that TOTAL /{p S- PERMIT TO
a w m he is licensed pursuant to life provisions of the Contractor's License
'i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the UL9��l
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE f�E1N-•f
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ; by any applicant for a permit subjects the applicant ton civil penally -
.fact more than five hundred d.11...($500R.) ALTER-DRAIN& VENT-WATER (EA.) 4.00 -
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 t OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the slmcture Is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Coda:The Contractor's License law does not apply to an owner of
property who builds or improves thereon,and who does Such work FIXTURES:PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE.-
1- 0 himself or through his own employees,provided that such improve-
menuarenotintendedoroffered for sale.IL however,we building GAS=.EA:SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the.ownegr GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of provir g that he did not build or far.
prove l'orpurposeofola.), INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Other
t ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS- 1 INC5 V.B. 5. 0 ASSESSORS PARCEL NO.
and Professions Code:'The Contractor's License Law does not apply
to an owner of property who builds at improves thereon,and who LAWN SPRINKLERS=OVER 5 IEA.) 1.00
contracts for such projects with a contractorls)licensed pursuant to
the Contractor's.License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lain exempt under Sec. ,B.&P.C.lir this WATER HEATER W/VENT "- 4.00 -
reason
Owner Data WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
I hcriby affirm that I have:a certific:de of consent to self-insure.
or a certificate of Workers'Connpensalion Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3800,lab.C.).//11
Policy No. Company s,QM, �U� &/r 0a,/ IVA.
O ❑pC',lifi"d copy is hereby furnished.CA(P W 069OJ RE$PRINK ENERGY T-24
z Z O Cert py is led Ih tl Ity mspectmn division.
Q •Applicant s, U.i�A.�t§�! MISC.- REFER TO ORD. Y❑ NO
Y ❑ N❑
F -
II Mw J/CERTIFICATE 01'EXFMPfION PROM WORKERS' PERMIT ISSUANCE 6.Q0 FLOOD ZONE A.L.U.C. .
W > COMPENSATION INSURANCE PLG.CONTE. :1 UC.NO. 'PLG.
Z ('I his section need not be completed if the permit is for one TOTAL /U YE] N❑ V❑ N❑
hundred doIhis IS 100)or less.)
U _O 1 artily that in the per9mnunce of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued.1 shall not employ any parson in any manner So as Io a a
U became Subject to the Workers'ConnpensaHon Laws of California. BUILDING �s
U a Dal° Appliemn .� ALAR OR ADD TO MECH. 4.00
} W NOTICE'I'0 APPLICANT': If,after making this Certificate of Ex-
F. ? emplion,you should become subject to"the Workers'Compensation APPCIANCE 4.00 PLAN CHECK a
provisions of the Labor Code, you must fWthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)"C.F.NU 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance 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',Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC �� S
1 certify that I have read this xpplicminn anA state that the above VENTILATION FAN (SINGLE) 3.00
inti enation is correct, I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMM H.P.or 100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTUISEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
" (WC) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertit}Ia gainst liabilities,judgments, costs and expenses which CONST.TAX
may a way�E}c sef'nsl Said City in consequence of the PERMIT ISSUANCE3.00
gr
tin f this pMECH.CONT. LIC.NO. MECH.
TOTAL TOTAL �/
gnature ul'Applican C tractor Date Ja .l^
INSPECTOR COPY