8391 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER•`r BUILDING
O j APPLICATION & PERMIT
ADDRESS BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 8391
// N R PLAN CHECK VALIDATION
•`A. Name M ! t QTV. ELECTRIC PERMIT FEE
PHONE
ANTRaciDRs
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 Ob
y Nf
Ic.No. LIGHTING FIXTURES 10.00/1.00
T
ADDRESS
aess c ons PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
onL rtECi PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.S A`/VLz c.rvo. SIGNS TRANS. 3.00
ADDRESS smc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 _J
ADDRESS MOTORS SEE FEE SCH. at
aooREss Ir
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 '7- 7o/s
<u v I hereby affirm tlmt 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y Gn (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
H o z Prolessions Cole,end my tic•Ase ix in full force and effect.
Z o m - Lailt Class Lie IN I to oz ®_ El El
o m r Date 'Contract.,
¢ y s BUILDING PERMIT
¢ ¢ a OWNER-BUIL DECL A'f10N
o a U MISC.- REFER TO ORD INFORMATION
w 3 LL I- I hereby affirm That 1 am exempt from lire Contractor's License VALUATION S/FT.
Hu0< Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE
Code:Any city orcounly which requires a permit to construct,alter, ?
aa improve, or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEG �1f J
A c u requires the applicant for such permit to file a signed statement that TOTAL •' PERMIT TO
n w
as he is licensed pursuant to the provisions of lire Contractor's License
r z i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the IA�C� ZE A,
a Business and Professions Code)or that he is exempt thcrefrmn and QTY. PLUMBING PERMIT FEE V
¢ c Ilio basis for the alleged exemption.Any violalinn oI'Seclion 7031.5 STORIES TYPE CONSTR.
a ; m by anyapplicant for a permit subjects the applicant to it civil penalty ALTER-DRAIN -WATER (EA.) 5.00
r1'not more than five hundred dollars(S500)J:
❑ I,as owner of the property,or myemployees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work..and the st ructurn is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code: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 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
• ownts are not
hde ownemployees,for sale.
if,ed that such improve- GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
mems are not intended or offered for sale.IE however the building
or improvement is cod within one year of tamplctio owner-
builder will have the burden of proving that l7did oatt builit d or inn - . - . .
BUILDING USE
,trove l'or purpose ofsaleRES IND CON PB 00w,
.). INDUSTRIAL WASTE INTER. 30.00
0 I,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. 6.00 ASSESSORS PARCEL NO.
and Professions Carle: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
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
0 lam exempt under See.-,B.AP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACG DATE ACC.FILE NO.
WORKS RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofcnnsenl to sell-insure, ZONING ENG.SITE NO.
or a certificate of Workers Compensation Insurunec,ora cenilanl
copy lhereof(Sec.3800,I.A.G).
-A, Policy No. Cool Dany -
❑ Cntlified copy is hereby fuin6led. L/Q/ q FIRE SPRINK ENERGY T 24
Z Z cII eY,ified <rP y is file) wit the c udp tfdn division. MISC.- RE;Z�9
Q Applicant Y ❑ N❑ V ❑ IN E]
Cy� CERTIIJ CATS Op EXEMPTION FROM WORKERS' PERMIT ISSUANCE FLOOOZONE A.L.U.C.
LU > COMPENSATION INSURANCE - PLG.CONTE, LIC.NO.
(L 0 (This section need root he completed if the pernit is for one Y❑ N❑ V ❑ N❑
Z) 2 hundred dollars IS 100)nr less.)
L) 0 1 certify that in Ole petl'onmance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California.
d Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING -3,F ,y-0
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you Should become subject to lire Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of,the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10p000EM.) 6.00 SEISMIC FEE S�
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the p"I'mro anac e
o1'.the work for which this prmit is issued(Sec. MICROFILM
3097,CN.C.). I HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's e
Terrier',Name UNamHEATI NO N IT(OVER 100,000 B.T.U.)9.50 ELECTRIC S7"
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and IB -7
H.P.or100,000B.T.U,) 6.00
hereby authorize representatives of this city to enter upon lire BID ER (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify end keep harmless the City of MISC.- REFER TO ORD.
Cupenimo against liabilities,judgments, costs analexpenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in um sequence of the
gmnlingaflhis permit MECH.CONT. LIG NO. MECH. -
<404f Aer- TOTAL TOTAL
/ $' a r AP tient./Coma i e TL .Sr
INSPECTOR COPY
I