8319 (3) APPLICANT. TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT 8319
ADDREBB
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
CANErsair PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• J vlsory .7-
COAHRIAGIrUR s OUTLETS-SWITCHES-RECEP 10.00/1.00
��. Idl e,- LIC.No, LIGHTING FIXTURES 10.00/1.00
ADDRESS/JTD/R-B PPLIANCES-RESIDENTIAL 4.00
PHONE / PANELS 10.00 DATE OF APPLICATION
OR "ITEC PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rEMP.METER OR POLE INS. 20.00 //
APPLI DDRESS MOTORS SEE FEE SCH. \ ,J�J
ADDRESS "'//////YYY:f.""'
SERVICE CHANGE 20.00
O o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /O S
F i w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
m a m BLDG. ELECT. PLG. MECH.
D z Professions Co and,m license is m full far n .9f e
o i m o License Cla '� Lice Numb
Date // Contractor
> y L
a Y Cc a BUILDING PERMIT
¢ 0 w a OWNIi R-BUILDER DECLARATION
A Q a u INFORMATION
w 0 y 1 hereby affirm that 1 am exmnpt from the Contracmr's License MISC.- REFER TO ORD
.. o A Law for the following reason.(Sec.]031.5,Businessand Professions VALUATION SIFT.
5 - PERMIT ISSUANCE 10.00
Code:Any city or county which requirese permit taco issuance,also
QS, ¢ improve,demolish,or repair any structure,prior to its issuance,also EIEC.CONTR. LIG NO. ELEC.
- D M requires the applicant for such permit ID file a signed statement that TOTAL
n w m w he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
H > Law(Chapter 9(commenciogwith Section 7000)of Division 3 oftbc
io Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
H o the basis for the alleged exemption.Any violation of Secl ion 7031.5 ST RIES TYPE CONSTR.
n 3 m by any applicant for a permit subjects the applicant to u civil penalty
ufuol it....than five hundred dollars($500H.): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees wwu'es as BACK FLOW PROTECT.DEVICE 4.00 OCC,GROUP ARES.UNITS
their Sole compensation,will do the work,and the structuithre is not
intended or offered for sale (Sec. 7044, Business and Prof'es'sions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds of improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employee,provided that such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the own - . - (EA.
1I GAS EASYSTEM OVER 4 (EA ) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON pa Omer
❑ I,as owner of the properly,am 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 Code:The Contractor's License Law docs not apply
to an owner of property Who builds or improves then•.....and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contract,for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA,200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B..gP.C.lin this WATER HEATER W/VENT 6.00
reason
Owner Dare WATER SYSTEM 5.00 ' ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSAl'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm t11a1 1 have a certificate ufconsent to self-insure.
or a certificate of Workers'Compensation Insurance, r a eerHfto,
ZONING ENG.SITE NO.
copy th c C
Policy '�`' n _
O ❑ vt led copYs fur lshed. FIRE SPRINK ENERGY T24
Z Z ❑ Ce tified copy •d with the city inspection division.
F0 All, t / / MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
CC N CERTIFICATE 01'EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
L 0 (This section need not be completed if the permit is for one 'TOTAL Y❑ N❑ V❑ rN❑
0 Z hundred dollars(S 100)or less'.)'
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
OL) become subject to the Workers Compensation Laws of California.
n Dam npph°ant ALTER OR ADD TO MECH. 5.00 BUILDING
),- to NOl'ICE 'f0 APPLICANT': If,u t,making this Certificate of 1:
F. ? emption,you should becmne subject m the Workers'Cumpcnsal ion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most Rlrthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction Icnding agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
® information is correct, I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indenmify and keep harmless the City of MISC.- REFER TO ORD.
Cup.rti 10 against liabilities,judgments, costs and expenses which CONST.TAX
any, (vat a rue against Said City in consequence of the PERMIT ISSUANCE
mayyfn10.00
yrs li of�s'er it, MECH.CONT. LIQ N0. MECH.
TOTAL TOTAL
I ttior"d plicianl1conlonclo, Dalc
INSPECTOR COPY
• i