12974 AIrPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
rBUI LDI NGTROJECY IDENTIFICATION PERMIT NUMBER
gD'I°ss /d' J a T�NT,4U APPLICATION & PERMIT- 12974
LAVE. T/Hb BUILDINGELECTRICAL-PLUMBING-MECHANICAL
Ge1NER'S PLAN LHECK VALIDATION
NAME 7.0t ,QEM Go/-714W-1Z �J CITY- ELECTRIC PERMIT FEE
PHONE �'7ZZ/ ,
` CONTRACTOP'S
NFU' /ZO. / UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. 17 12 0LIGHTING FIXTURES 10.00/1.00
CNTHADDRESS GRs
A5 PDPLp X12 PPLIANCES-RESIDENTIAL 4.00
iC V�./�/ } p
/1'HONEVIS-03y' PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG, SPECIAL CIRCUIT
5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP. METER OR POLE INS. 20.00
ADDRETS 3/5' .BRoK./aw ,QQ. MOTORS SEE FEE SCH.
or�oiv)-,4G CA- LfSO$O SERVICE CHANGE 20.00 / 1
w p p LICENSED CONTRACTORS DECLARATION `�
¢ U I hereby affirm that I am licensed under provisions of Chapter 9. ISSUANCE DATE
a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. I PLG. MECH.
Professions Code.and my license is in full torSe
zO z License Con Number/7T/lf� ❑ ❑ ❑
'9 yF Lio Contractor
rt w ¢ OWNFR-BUILDER DECLARATION BUILDING PERMIT
U REFER TO ORD INFORMATION
E:
;LL H 1 hereby affum that I nm exempt from the Contractor r Liceme MISC.- VALUATION S/FT.
F .. 0 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
N,A Cale:Any city or County which requires a permit to construct,after,
2 Qimprove,demolish,or repair Wry structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
o u requires the applicant for such permit to file a signed statement that TOTAL PERMIT
w $ he E licensed pursuant to the provisions of the Contractor's License
H z i Law(Chapter 9(mmmenciagwith Section 7000)of Division 3 ofthe ("
¢ Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ _$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ; _ by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500),I:
❑ 1,as owner of the pRcpcHy,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES:UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5,00
Code:The Contraetir's License Law does not apply to an owner of
C - \
property who buildsorimp roves thereon,vidwho does such work FIXTURES-PER TRAP 6.00 yo Fr,FLDOR gRI:A rornueREAGE
•J1 himself re of ince his own employees,provided that such im building
rent are not intended or.(fared for sale.If,however,the briding GAS-EA:SYSTEM-11NC.40UTLETS 6.00
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 DON PB On.
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as;owner of the property,am exclusively contracting with Cl ❑ ❑ ❑ ❑
licensed Contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cade:The Contractor's License law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPR IN KLERS-OVER 5(EA.) 1.00
Contracts for such projects with a conlractons)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITAR V-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I ani exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
N'ORKERS'COMPENSATION DECLARATION WATER TREATING EOUIP. 5.00
I hereby affirm that I have a certiflmle of consent to self-insure, ZONING ENG.SITE NO.
or a certife te of Workers'Compensation Insurance,or a certified
Copy thereol'i 3800, Ml�4�G Lnb.C.I
Policy No. Company r� Y
O ❑ cedified copy is he b fu ni had. FIRE SPRINK ENERGY T-24
Z Z O1Certificd ropy is fi wi0 the cit inspe tion division. MISC.- REFER TO ORD.
O Applicant - -� Y ❑ N❑ Y ❑ N❑
c h CERTI F : O F M SRS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.D.L.
lL > COMPENSATION INSURANCE. PLG.CONTE. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
CL 0 (This section need not be completed if the permit is for one TOTAL
::) Z hundred dollars IS 100)or less.)
U O 1 certify that in the PeTfurmmnce of the work for which this per, CITY. MECHP)WERMIT FEE FEE SUMMARY
LL F mit is issued.1 shall not employ any person in any manner so as to rrll''UUL�/
U become subject to the Worken Compensation laws of Californu.
w Date Applicant ALTER OR ADD TO ME 5.D0 BUILDING
} tgi NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F. ? emption,you should berolne subject to the Workers'Compensation APPLIANC 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 QF.M.1 4.00
CONSTRUCT ION L17NDING AGENCY AIRHANDLI 0.FM) 6.00 SEISMIC FEE
Thereby affirm that there is a construction landing agency for /L EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this pernit is issued(Sec. /O MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify thaw I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00
_ hereby authorize representatives of this city to enter upon the BOILER-COMP (Over IOQOOOBTUI SEE FEESCH. MECHANICAL
above mentioned property for impaction purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
CupeHino againj liabilities,judgments, costs and expenses which CONST.TAX
may in any w y accrue .gain said ity in consequence of the PERMIT ISSUANCE • 10.00 Q
gran ' perm' r MECH.CONT. LIQ NO. MECH.
S w- TOTAL ��V`. TOTAL
5 lis n ontmdor ate ��'
OFFICE COPY