7158 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 7158
FDDRESS
UILDIN
A" BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
t
OWNER S PLAN CHECK VALIOATION
NAME -} .�J "/zJ QTY. ELECTRIC PERMIT FEE
- VO /C V�vVNONE (�
NAME CTors OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
UC.NO. / LIGHTING FIXTURES 5.00/1.00 S�
CADDRESS
REAPPLIANCES-RESIDENTIAL 4.00
ONTRA
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No, SIGNS TRANS. 3.00
aoonesR ENG SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.MFyTER OR POLE INS. 15.00
APPLICANT'$ 1
AooHEss MOTORS; SEE FEE SCH.
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION
U E, I lic"I"at that I 'u nI licen>•L•d under provisions of Chapter 9 ISSUANCE DATE
w Q H Icon rmucing with Section 7000)of Division 3 of the Rosiness and BLDG. ELECT. PLG. MECH.
w z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
z 0 m - License Class Lia Number-
2 �z
umber2,z Dote Contractor a
r,-- -
m ¢ a OWNER T
-BUILDER DECLARAION BUILDING PERMIT
INFORMATION
_ a e
A
3: - 1 hereby l LiMISC.- REFER TOORD
x w g u r erey alion that I am exempt from the Contractor's cense VALUATION $/FT.
H ..'0 a Law for the following reason.(Sec.703 1.5,Businessand Professions PERMIT ISSUANCE 6.00
Codc:Any city or county which requires a permit to construct,alt",
IE ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC. V V
K D or requires the applicant for such permit to file a signed statement that TOTAL // PERMIT TO
1 es oc he is licensed pursuant to the provisions of the Contractor's License ? //
His Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe SlUR'4Gc s'/jC,
a - ,Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
K 1- o the basis fnr the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER IEA.) 4.00
of not mom than five hundred dollars(5500).):
❑ L as owner of the property,ur my employees with wages as BACK FLOW PROTECT. DEVICE 2,00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered 1'or sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such'in
f!,ove-
Irent$are let nmrndcd or offered for sale,If,however.the budding GAS-EA.SYSTEM-11 NC.4 OUTLETS 4,00
or improvement ossold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA) 100 BUILDING USE
builder will have the burden of proving that h . . .
e did not build or im- RES IND CNG PB Amer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,um exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Profession s Code I'lie Contruclor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a cuntmam s)licensed pursuant to
the Contractor.,Liceme Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I ant exempt under Ser.—,B.&P.C.tar this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA1'ION DECLARATION WATER TREATING EQUIP. 4.00
1•he,do,a 11non that l have accNitiem,of am..of to sell-im,uCe' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C). -
policy No. - Company
O ❑ Coribied copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TOORD.
Q Applicant Y ❑ N❑ Y ❑ N❑
� N
CER'I'I FICAI E OIr EXEM PT'ION FROM WORK ERS' PERMIT ISSUANCE 6.00 -FLOOD ZONE A.L.O.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
01'his section need not be c mplcled if the permit is fnr one TOTAL YE] N ❑
❑ Y ❑ N
z
hundred dollars(S 100)gr less I
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL F mit is issued, I shall not employ any person in any manner so as to
U beconm subject to file Workers'Compensation Laws of California.
ELI Laic Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} In NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? eruption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this pernut shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000GEM.) 5.00 SEISMIC FEE s'U
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work tin which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender', de
Ad
Lender's AddreHEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
ss
1 certify that 1 have read this application and sure that the shove VENTILATION FAN (SINGLE) 3.00
btl'onlation is correct. I agree to comply with ell city and county PLUMBING
ordinances and state laws relating to building constrocl run, and BOILER-COMP(3 H.P.Or100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. 801 LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Copertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
9 . g`ofthis permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL d IF -i
So mutureof m1woUlcontimeftiT Date
INSPECTOR COPY