C7164 APPLICANT.TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ONPERMIT NUMBER
/
BUILDING APPLICATION & PERMIT
v
ADORES E� � /q�14--� L" PUP
7164
//t.ry BUILDING-ELECTRICAL-PLUMBING-MECHANICA
0 NUI S �qr� C - I ` PLAN CHECK VALIDATION
NWME• t�Wcc.T� OFF, ? QTY. ELECTRIC PERMIT FEE
_�Nr NE r
Nome ACTars UTLETS-SWITCHES-RECEP 5.00/1.00 �a
LIC.No. LIGHTING FIXTURES 5.00/1.00 _1
CONTRACTORS APPLIANCES
PHONE
4.00
ADDRESS
PHONE PANELS 5-00 DATE OF APPLICATION
ARCHITECT � _L/ , f CSIGNS 6_�� PLAN CHECKFEE P.C.NO.
OR rCY//)fir/-TJf �lL,~
IT
LIC,NO SIGNS TRANS. 3.00
ADDRESS /.P0. fJr/070l 57 tr fra7 SPECIAL CIRCUIT 5-BB PERMIT VALIDATION
p,(14(/ �I``�� �J�/ JIB Z1P'P EMP.METER OR POLE INS. 15.00
Anr$
ADDRESOHEss MOTORS' ` SEE FEE SCH.
SERVICE CHANGE , 10.00 �/�
, 00 LICENSIi1)CONTRACTORS DECLARATION '1 +
< v I hereby of firm ihm I am licensed under provisions of Chapter 9 _ ISSUANCE DATE
w G i Ictur mencing with Section 7000)of Division 3 rf the Business and t 8 ELECT. PLG. MECH.
F N i I'rol'cxsions Code,and my license is in full force and effecl. ❑ ❑ E]z o m— License ClassLie.Number
Z Date Contractor '
a y E BUILDING PERMIT
¢ ¢w a OWNER-BUILDER DECLARATION INFORMATION
F 0 a F REFER TO ORD f
wI hereby affirm that I am exempt from the Contractors License MISC.
�+ VALUATION $/FT.
F u- o j Law li+r the following reason.(Sec.7031.5,Business and professions PERMIT ISSUANCE 6.00 '�
Code:Any city or county which requiresa permit toconstruct,alter, (�
Qto ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
to
O ¢ requires the applicant for such permit to file a signed statement that TOTAL `fp _ PERMIT TO
s w m" he is licensed pursuant to the provisions of the Contractor',License l
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ F o the basis for the alleged cxemplion.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicanmi
t fora pert subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500)): ..'"�
❑ h as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the stmcnre Is not
intended or offered I.or sale (Scc. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4-00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work fillFIXTURES-PER TRAP 4.00 Zz SO.FT.FLOOR AREA TOTALACREAGE
• himselfor through his own employees,provided Illat such improve
Anot lot Pdvd or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
eme f rs sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BuaomG USE
ill have the bunters of proving Ihul he JiJ not M1uild or im RES IND CON PB Gone,
pugssose of sale)- INDUSTRIAL WASTE INTER. 2 ,00sowner of the property,am exclusively contracting withontractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL N0.
ssione Codd'I'hc Cnntrunoi n Liccnsc f ace docs not apply
to an owner rl property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlmctotts)licensed pursuant to
the Cmunetor's License Law. SEWER-SANITARY-STORM EA.2001t/8.00 TRACT NO. PARCEL NO.
❑ I:un exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 4.00
T oCYm
Ow WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
wO iRSII1 _NSATI ECLARATI dd WATER TREATING EQUIP. 4.00
I hereby affirm OnH l have acenificine fcons.H to x, -insert
ur a cerlificale of Worked'Compersulion InsuranceZONING,or a cc,tifieA ENG.SITE NO.
ropy Ihercof(SCc.3SHII,La).C.). 4
Policy No. Company
O Cl Certil_wd copy is hereby furnished. FIRE SPRINK ENERGY LZ4
Z Z ❑ Certified copy is Bled with the city inspection division.
O Applic:ml MISC.- REFER TO ORD. YE] No v0 N[]
F— y PERMIT ISSUANCE - 6.00 — FLOODZONE A.L.U.C. '
W CIiRI'l l'ICCO' OF ISX ION ION FROM WORKERS'
CL COd not
INSURANCE like PLG.CONTE, LIC.NO. PLG. Y❑ N[] Y❑ Np
CL O (This section 10J not bu completed if the permit is for one TOTAL
� Z hundred Dollars 151001 nr less.)
U O 1 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
U become subject to the Workers'Compunutmn Laws of California.
UJ
Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING J V
} W NO'T'ICE '1'O APPLICANT': If,alter making this Cerlil'icale of Ex-
F Z emlptiom,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK ;
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONST'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE J
1 hereby aflifm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
lite performance of the work for which this permit is issued(Sec. MICROFILM
3097.Civ.C), HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I eerily that l has,read this applicationand stuc that the athose VENTILATION FAN (SINGLE) 3.00
AdIRL 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.) 4.00 V
hereby authorire representatives of this airy 1v cntef upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property to,inspection pulp,
(We) agive to save, indemnify and keep harmless Hit, City of MISC.-•` REFER TO ORD.
Cupefino against liabilities,judgments costs and expenses which CONST.TAX }
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
granlin� thjs penin MECH.CONT. LIC.NO. TOTAL
TOTAL $7I5
4{I eof App¢ant/bntracoor 1)5te/
INSPECTOR COPY