12836 A€aPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT P_N ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUO.DMG �-� APPLICATION & PERMIT ^
g'DRESS BUILDING - ELECTRICAL-PLUMBING-MECHANICAL G
' OWNERS836
PLAN CHECK VALIDATION
T NAME CITY. ELECTRIC PERMIT FEE
DNE G
.v � corurRAcrORs UTLETS-SWITCHES-RECEP 10.00/1.00
NOM /
op ND q LIGHTING FIXTURES 10.00/1.00
10TCT
ORS PP LI ANCES-RESIDENTIAL 4.00
'T RDNE PANELS 10.00 DATE OF APPLICATION
ARCHCT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER.
Lc.NO. SIGNS TRANS. 3.00
ARCH.OR ENO. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
-ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT a MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARATION O
¢ v u 'I hereby affirm that 1 am licensed under provisions of Chapter Y A An CE DATE
(commencing with Section 7000)of Division 3 of the Businessand Llluvttr. PLG, MECH.
H a Professions COOS,..d my license¢in fall furS ethe (, ❑
Ti eat Class Lic.Number/- L{._ ❑ El Z r ate•)_��_�� Contractor
U1 BUILDING PERMIT
¢ ac w c OWNER-BUILDER DECLARATION
E o A REFER TO ORD INFORMATION
. it LL N I hereby affirm that I am exempt from the Contractor's Licence MISC.-
LL O j law for the following reason.(Sec.7031.5,Businsand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
E - 0 Code:Any city or county which requiresa permit to construct,alter, /DO O 0
¢ ¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. D
ELEC.
o LLrequires the applicant for such pernsil to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
Hzi
Lw(Chapter 9(commencing with Section 7000)of Division 3 of the �L/vf/-� /A/7a;(/
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
f ¢0
¢ H� the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
a ; , by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ I,asowner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP. RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sea 7144, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code: The Contractor's License law does not apply to an owner of
-r property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employers,provided that such improve GAS-EA.SYSTEM-11NC.40UTLETS 6.00
>•� ments are not intended or offered for Sale.If,however,the building
f, or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ ],as owner of the property,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 does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
contacts for such projects with a comactor(s)licensed pursuant to
the Contractor's License Lew. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACL.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
20 copy thereof(Sec.3800,Lab CA '
Policy No. Company #S4
O ❑ Certified copy is hereby Turrihod. FIRE SPRINK ENERGY T 24
Z Z� C I copy is filed with IT city p tion division.
L_X� App❑lican _ MISC.- REFER TO ORD. Y❑ N❑ Y ❑ INC]
Crw CTIFICATEOFEXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
U COMPENSATION INSURANCE PLG.CONTE, LIC.NO. PLG.
CL 0 (This section need not he completed if the permit is for one TOTAL y E] N❑ v ❑ N❑
Z) Z hundred d.11.,($100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
become Subject to the Workers'Compensation Laws of California.
O ED Dace Applicant BUILDING t OV
a ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: If,after making this Cenifcme of Ex-
F Z emplion,you should become Subject to the Workers'Compensation APPLIANCE 5.00 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=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n correct. 1 agree to comply with all city and county PLUMBING
ordinanm and ru
state laws relating to building construction, ad
BOILER-CONT(3 H.P.or 100,000 B.T.U.) 6.00
ew hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
`�•'. above-mentioned property for inspection purposes.
(We) agree m save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupanino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10,D0 CONST.TAX
say in any way accrue against said City in consequence of the
gran gDflhispernit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL *o 6'
e ore of Applicant Contractor Date
OFFICE COPY