7110 (3) '
f , APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
I BUILDING PROJECT IDENTIFICATION +, PERMIT NUMBER
RmLOWc �O�f70 /✓D/2Ti/OHK $Qu9/zt APPLICATION & PERMIT .
ADDo ESs O
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OwrvE 's PLAN CHECK VALIDATION
NAME _ 50
QTY. ELECTRIC PERMIT FEE 1'
® PNONE ' - ,J
NAME cons OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
LC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS `
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE ' PANELS S.00 DATE OF APPLICATION
ARCHITECTSIGNS - 6.00 PLAN CHECK FEE P.C.NO.
OR
E NGINEEH
LIC.No, SIGNS TRANS. 3.00
AARCH OR DDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS Y;_MOTORS SEE FEE SCH. /J
' S 430Y& SERVICE CHANGE 10.00 0 1
w O o LICENSED COAT RACI ORS DECLARATION E
a u u I hereby xl'Orm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H rt e_ (commencing with Section 7000)of Division 3 of the Business and BLO ELECT. PLG. MECH.
o z Professions Code,and my license is in full force and effect ❑ ❑ O
z o= License Class Lie.Number
o z Date Contractor
a y E BUILDING PERMIT
rc rt w ¢ OWNER-BUILDBR DECLARATION INFORMATION
ti:
3°' N 1 hereby affirm that 1 am exentpl from the Contractor's License
MISC.- REFER TO ORD
.. 0< Law for me following reason.(Sec.7031,5,Businessand Professions PERMIT ISSUANCE VALUATION
� - Code:Any city orcounty whiehrequiresxpermntocoastruc tatler, 6'00 ry_/�/��
or Q O improve,demolish,or repair any Structure,prior t0 its issuantt,x150 ELEC.DDNTR. UC.NO. ELEC . 00
K O ¢ requires the applicant for such permit t0 file a signed statement that TOTAL PERMIT TO
u w m he is licensed pursuant to the provisions of the Contractor's License I
-rzi Law(Chup4rp(commencing with Section 7000)of Division 3 ofthc I 1 �'-
e Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE L�1
r $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A by any applicant for a permit subjects the applicant toe civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).1:
I,as owner of the property,or 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 for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'Phe Contractor's License Law does not apply town owner of
property who builds or improves thereon,and who dot's such work FIXTURES-PER TRAP 4.00 SOFT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
meats are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement is sold within line year of completion,the owner- r
builder will have the burden of proving that he did not build or am. GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER, 20.00 ES IND CON PB Ome
nr
- ❑ 1,as ower of the property,am exclusively contracting with ❑ ❑ ❑ ❑
_ licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 NASSESSORS PARCEL NO.
and Professions Code:'I'lie Contractor'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 contruatorls)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ hum exempt under Sec ,B.&P.C.far this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK Ii RS'COMPF NSA'IION DECLARATION WATER TREATING EQUIP. 4.00
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.).
Policy No. Compmry
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division.
O Applicant MISC.- REFER TO ORD. YE] N❑ Y E] N❑
M w CER'I'I FICATF OF EX 17MPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE ALU c.
W �_ COMPIiNSAI'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
6. 0 (Phis section need not be completed if the permit is for one TOTAL Y C] N❑ V❑ N❑
::) 2 hundred dollars IS 100)or less.)
U O 1 certify that in the perfurmance of the work In,which this per. QTY. MECHANICAL PERMIT FEE - FEE SUMMARY
LL F- mit is issued,1 shall not employ ally person in any manner so as to
OU become subject V the Workers Compensation Laws of California.
w Date Applicant BUILDING /
a ALTER OR ADD TO MECH. 4.00
} to NOTICE "f0 APPLICANT: If,after making this Certificate of Ex- '
F ? eruption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK O
provisions of the Labor Code, you must forthwith comply with FEE /
U such provisions or this permit shibil-be deemed revoked. AIR HANDLING UNIT(TO 10A000.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0O00GEM.) 5.00 SEISMIC FEE
I foully alarion that there is a construction lending agency fur EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work Ihr which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T-U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certily that I have read tills application and Mme that the above VENTILATION FAN (SINGLE) 3.00
inforuatiun is correct. I agree to comply with all city and countyPLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby nuthoriec representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ubuve-mentioned property for inspection purposes,
OVe) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cuperino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
grantof mispenmit. MECH.CONT. LIC.NOf MECH.
� .� /uo TOTAL TOTAL (�
Signinfure if Applicant Contrctor 7 fate r
INSPECTOR COPY