C8466APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
(�I
8 6
BUILDING
ADDRESS(�
ADDRESS/&9,00 -r7"�V�'Js C����
OWNER'S
NAME
mHONI=
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
� o '
6;-Ie
S� 3�'-(1 I`� 1-'-
DATE OF APPLICATION
NAME
Lrc.No.
OUTLETS 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS '
ADDRESS
PHONE 1_
PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00
oa TE ils�tF.
ENGINEER
'uc.No. 1
PANELS IOV ER 200 AMP) 20.00
.
PLAN CHECK FEE P.0N0.
SIGNS TRANS. 3.00
ADDRESSE c.
Z,P
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
r
�.
,/J/
5 /n.i�pC��
IBSt7/AN�CUDA4
LOQ ELECT- PLG. MECH.
❑ ❑ ❑
EMP. METER OR POLE INS. ',{ 20.00
APPLICANTS GIc�` -
ADDRESS T 1 -
1
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm That I 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
License Class Lic. Number
Date Contractor
OWthat IBUILDER DECLARATION RATION
1 hereby affirm that 1 am exempt from the Contractor's License
Code:Law nycrthe llowingrewhih(Sec.
requi3Lapermincssand Professions
Code: e,demyor county pair any srucitsap riorttoconstrvet,alter,
improve, demolish, or repair any permit toff prior to its issuance, x150
requires the applicant for such permit TO file a signet) statement that
lie is
he is licensed pursuant In the provisions of the Contractor's 3ofilic
of Division 3 of the
Law (Chapter r (commencing with that
7s exempt
Business and Professions Code) or Dat h i is exempt Therefrom and
the basis for the alleged exemption. Any applica of Section en LS
subjects the applicrnt lea civil penahy
by any applicant fora perian hundred
of notmom than five hundred dollars (5500).):
❑ I, as owner of the property, or my employees with wages as
their suit compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7040, Business and Professions
Code: 'Fire Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsare not intended or offered for sale. If, however, the building
or improvement is sod within one year of completion, the owner.
builder will have the burden of proving that he did not build or im-
Prove for purpose ofsale.). `+i,
IQ 1, as owner of the property, am enclusivaly contracting with
" •Used contractors to construct the project (Sec. 7044, Business
ant fessions Code: Tire Contraclnr's. License Law does not apply
too an o - of property whobuild, improves thereon, and who
contracts 1'0 Ich projects with'a contmetorfs) lic-vnsed pursuant to
the Contractor icense Law. 1
O lam exem under ec. ,B.&P.C. for this
reason
TEMP. POLE 30.00
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
/O �OV
5/FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
OTV. PLUMBING PERMIT FEE
OR 5
VPE 9TR.
1`s. <•.
ALTER-DRAIN&VENT-WATER (EA.) 5.00
BACK F LOW PROTECT. DEV ICE 4.00
OCC. GROUP
RES?UWTS"'�-
kl.
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES - PER TRAP 5.00
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
Ownur- ' ' Dat
WORKERS' : MPL , DECLARATION
1 hereby affirm that 1 have a state of consen.Jtosdf-ine,oure.
ora certificate ofWorkers' Compensation Iisumnec, or a certified
copy thereof (Sec. Lab.CJ. -
PONO. Co
WATER SYSTEM 5.00
ACC.OATE
"
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
ZONING
ENG. SITE NO.
MISC.- REFER TO ORD.
0 Certified opy is hereby (
C1' I
famishedthe
Certified copy is filed with wiith the city, inspection'Jivisinn.
Applicant _
FIRE SPRINK
Y E] N❑
ENERGY T 24
V E] N❑
CERTIFICATE 01' IiXEMPTION FROM WORKERS'
COhl1'ENSAT10N INSURANCE \
1'fhis section need not be completed if the permit is for one
hundred dollars i$ too)or less) A\
I certify that In the performance of the work for wlrisCh this per-
msu
it is ised, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Date Applicant
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y ❑ N ❑
A. LU.O.
Y ❑ N ❑
PLG. CONTRI ❑C. NO.
1
PLG.
TOTAL
-
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
y_V
,ALTER OR ADD TO MECH. 5.00
NO'T'ICE; 'f0 APPLICANT: If, after making this Certificate .1 Ex-
emption, you should heer ... subject to the Workers' Compensutiun
provisions of the Labor Code, you nwst forthwith comply with
such pmvisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGIiNCY
1 hereby affirm that There is a construction lending agency for
the perlormmnce of the work far which this permit is issued (See.
3097, Civ.C.L
Lender's Name
L`{ender'rAddress f
kl certify that 1 have read this application and State Hurt the above
i nfonn:vion'is correct. I agree to comply with all city and county
ordinances and state laws relating R) building construction, and
hereby authorize representatives of this city Ho ewer upon the
above-mentioned property for inspection purposes
agree to save, indemnify and keep harmless the City of
Cupelh against liabilities, 'udgments, costs and expenses which
may in an way Retro• a st said City in conttquence of the
granting nl t 's perms
z.
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10MC.EM.) 6.00
SEISMIC FEE
•70
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATI NG UNIT(OVER 100,000 B.T.U.)9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER-COMP13 H.P. or t00,0008.T.U.) 6.00
BOILER -COMP (Over t00,0008TU15EE FEE SCI.
MECHANICAL
s
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIQ N0.
MECH.
TOTAL
TOTAL
/ ,j O
o pp It t/ o acro -' Date
INSPECTOR COPY