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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
PERMIT NUMBER
n ,
LL,SY7�TTc ,,,S,,,r
ABUILDINGDDRESS
AooR2O Z30 5rellem g C/• ,BLvn.v
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
6266
OWNER'S
PLAN CHECK VALIDATION
NAME �/
V/: L/ Z '/,91S? er,FPHONE .`G-�w
QTY. ELECTRIC PERMIT FEE
CONTRACTORS
NAME
SuPEQ/6KAu76-s/�K•��A 87�2�
LIC. NO.
UTLETS'SWITCHES -RECEP 5.00/1.00
LIGHTINGFIXTURES 5.00/1.00
CONTRACTORS
ADDRESS Das M��T%I/wI
///
PPLIANCES- RESIDENTIAL 4,00
PANELS 5.00
PHONE 1Z%Z
DATE OF APPLICATION
KRCOTTECTPLAN
OR
ENGINEER
uc.No.
CHECK FEE P.C. NO.
SIGNS TRANS- 3.00
ARCH. OR ENG.
ADDRESS
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
ZIP
/
A
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
�('/-7
LIGIiNS1iD CON'I'ftACl'ORS DECLARATION
I hereby allirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions ns Code, and my license is in full farce and effect.
LicenseLie. Number 9
Dile Contractor
ISSUANCE DATE
B
ELECT.
❑
PLG. MECH.
❑ ❑
t
BUILDING PERMIT
OWNER -BUILDER DECLARATION
I hereby allirm Ih:n I ;un exempt from the Contractor s License
Law lin the following reason. (Sec. 7031.5, Businessand Proffessions
consuct, alter,
Code: Any city or county which requires a permit to tr
improve, demolish, or repair any structure, toff prior to its also
INFORMATION
MISC. - REFER TO ORD
VALUATION
p p .-
2/ /��
$/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIG NO,
ELEC.
r statement
req mics the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
,
TOTAL
PERMIT TO `
QTY. ,. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Sect ion 7000) of Division 3 of the/
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).):
/
STOHMES
T YPE CONSTR.
/
r
ALTER-DRAIN&VENT-WATER (EA.)4(OO
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK F LOW PROTECT. DEVICE 2.00
OCs,. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4:00
intended or offered for sale (Sec. 7044, Business and Professions
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 ' 4.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve-
cents are not intended or offered for sale, If, however, the building
-
,
GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.). - '.I.¢•
❑ I, as owner of the property, am exclusively Atoicting with
GAS - EA. SYSTEM. OVER 4 (EA.) 1.00
BUILDING USE
RES IND PB Other
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. _ 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSo MIRCEL NO.
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractors License Law dues not apply
to an owner of property who builds or improves thereon, and who
contracts for such projects with a commoo o licensed pursuant to
Illi, Cmumctors License Law.
SEWER -SANITARY -STORM EA. 200ft/6.00
TRACT No,
PARCEL NO.
❑ tum exempt wWer Sec. .B.&YC. for this
Is.1.11
WATER HEATER W/VENT 4.00
owner Date
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE N0.
WATER TREATING EQUIP. 4.00
WORK ERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of chosen, to sell -insure.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof(Sec. 3800, Lab.C.).
Policy No. COm I �/
❑ Ccr il9 copy is he{ y'f- s
_1i
FIRE SPRINK
ENERGY T49
(d.
❑ C tlfic mpY is Ilcd w t 1 city 'Icctlnn Jivison.
Applic it
Y ❑ N❑
Y ❑ N❑
MISC. - REFER TO ORD,
TIPICA'I'ES OIr EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.LUC.
PLO. CONTR. LIC. NO.
PLG.
TOTAL
COM 111,SATION INSURANCE
I'I'his section need not he completed if the permit is for one
V ❑ N❑
V ❑ N
MECHANICAL PERMIT FEE
FEE SUMMARY
"
hundred dollars IS 100) or less.)
1 certify that in the performance of the work for which this per -QTY
mit is issued, I shall not employ any person in any Toner so as to
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. - 4.00
NOTICE FO APPLICANT:: If, alter nuking this Certificate of Es-
emption, you should become subject to the Workers* Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
CONSTRUCIION LENDING AGENCY
APPLIANCE 4.00
PLAN CHECK
FEE
ZS.77
AIR HANDLING UNIT (TO 10=C.F.W 3.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00
SEISMIC FEE
Z•��
EXHAUST HOOD (WITH DUCT) 2.00
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATI NG UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and state that the above
information is Correct. I agree to comply with all city and county
ordinances unit state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER-COMPI3 H.P. Dr 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU)SEE F EE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above routioned property for inspection purposes.
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harmess the City of
CuperL against liabilities, judgments, costs and expenses which
nuy'in 'ny way ac see agalns said City in consequence of tits,
granting fthisper
=6t_41^
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIG NO. MECH.
TOTAL
TOTAL
S
S' lure of Applicant/Contractor Date
INSPECTOR COPY