7218APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
7218
BUILDING
ADDRESS f Sgoo �/��p J
Sr ili�'a� @f�QL'�C el�d
OWNER'S
NAME
IIGYI.M. t PHONE
/I/ O
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NANMEn4croRs
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
LIC. NO.
cOILDRs
ADuli
RESS ss
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
PHONE
DATE OF APPLICATION
ARCHITECT
OR
ENGINEER
uc. No.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
numiEsc ENG.
ZIP
SPECIAL CIRCUIT 5,D0
PERMIT VALIDATION
9�_
EMP. METER OR POLE INS. 15.00
ADDRESNrs
MOTORS SEE FEE SCH.AOOREss
SERVICE CHANGE 10.00
9/ r
�U
LICENSED CONTRACTORS DECLARATION
I hereby affirtn that 1 am licensed under provisions of Chapter 9
(Commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
Class Lic. Num her
ISSUANCE DATE
BLDG. ELECT.
El
PLG. MECH
.Professions
❑
LrI-icense
Cord rector
BUILDINGPERMIT
OWNER -BUILDER DRCLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec 7031.5, Business and Professions
Code: Any City m county which requires a permit to construct, alter,
improve,demolish, or repair any structure, priorbl its issuance, also
INFORMATION
MISC. — - REFER TO ORD
VALUATION
S/FT.
PERMIT ISSUANCE 6,00
ELEC. CONTH. LIQ NO.
ELEC.
requires the applicant for such permit to file a signed statement (hat
he is licensed pursuant to (he provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 70000of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
TOTAL
PERMIT TO
^
OTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects We applicant Ina civil penalty
of not marc than five hundred dollars ($500).):
ALTER -DRAIN -WATER (EA.) 4.00
❑ I, as owner of the properly, or my employees with wages as
Him sole compensation, will do the work, and the structure is not
BACK F LOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Cade: The Contractor's License Law dues not apply to an owner of
property who builds Or improves Ilercon, and who does such work
FIXTURES - PER TRAP4.00 UI[
SD. FT. FLOOR AREA
TOTAL ACREAGE
hinlsclt' ,, III mugh his awn employees, Provided thal such improve-
mm�lSarenolintendedorofferedfor sale. If, however, the building
GAS-EA.SYSTEM-11NC.40UTLETS 4,00
or improvement is sold within one year of completion, Nthe Owner-
builder will have the hnen offs imving that he did not build or -
ProsemrpoRmseofSele.).
I, as owner of the property, um exclusively contracting with
licensed cortuctor, to construct the project (See. 7044, Business
and Plafe ]Ion]' Code. 'I lic C'Onlraelln', License Law due, not apply
to an owner of property who builds or improves thereon. and who
contracts for such projects with a contractoos) licensed punuanl to
the Contractor's License Law.
. ..
GAS - EASYSTEM -OVER 4 (EA) 100
BUILDING USE
REB IND CON ve Omv—
El ❑ 11 El 1:1❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
�
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL -NO.
❑.f am exempt under Sec. ,B.&P.C. for this
rcnson
WATER HEATER W/VENT 4,00
0.,2 Date
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKB RS'COMPFN'SATION DECLARA'T'ION
I hereby affirm that I have a certificate of coosenl to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy tlercal'(Sec. 3800, I-ab.C.).
Policy No. Company
FIRE SPRINK
ENERGY T 24
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.
Applicant
Y❑ N❑
Y❑ N
MISC.- REFER TO ORD.
CERTIFICA'1'C OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.PLG.
TOTAL O '�to
C'OMPENSAT ION INSURANCE
(I its section need net be completed if the permit is for one
V ❑ N ❑
Y ❑ N ❑
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars IS 100) ., less,)
1 certify that in the performance of the work for which this per-
mit is issued. I shall not employ any person in any manner so as to
BUILDING
become subject to the Workers' Compensation Laws of California.
Dale Applicant
ALTER ORADD TO MECH. 4.00
I'WE TO APPLICANT: If, after making this Curtilite of E.-
NO'co
emption, you should become subject to the WorkersCompensation
APPLIANCE 4.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions Or this permit Shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00
SEISMIC FEE
CONST -RUCTION I.FNDING AGENCY
I hereby affirm that there is a construction lending agency lint
EXHAUST HOOD (WITH DUCT) 2.00
the perlormance of (he work for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
I certify that l have read this application and,talc that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER - COMP(3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 1UQ000BTU) SEE FEE SCH.
_
MECHANICAL
hereby authorize representatives of this city to enter upon the
aboveanentioned properly for inspection purposes.
misc.- REFER TO ORD.
(WaI ag a Io save, indemnify and keep hnnnless the City of
Cupelf., gainA liabilities, juJgocols, costs and expenses which
may it y y ac IC 'gr;,St aid City in c.nse9uence of the
grauf IthW ller
a �T
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
Signature ol Applicant/ConhhlrI Date
INSPECTOR COPY