8586APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON
APPLICATION & PERMIT
ILDING-ELECTRICAL-PLUMBING-MECHANICAL
PERMIT NUMBER
'
8586
BUILDING s
ADDRESS
OWNER'S
NAIVE
PHONE
-
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
Com cons
LIC. NO.
OUTLETS - SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
ADDRESS L _
�PIhFe
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
A RITE
on
ENGINEER
uc. NO
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.f
SIGNS TRANS. 3.00
'ADDRESS END
ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
PAID
JUN 11o85
d
IlA.1F DATE
BLDG. ECR.
�-
TEMP. METER OR POLE INS. 20.00
A oR asTS
-
MOTORS SEE FEE SCR.
SERVICE CHANGE 20.00
LICENSED CON' I' RACTORS DECLARATION
I hereby affirm that I am licensed tinder 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,Numbnr
Dme Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Professions
Law for the ity., Countng which c. requires a permit to construct,
Code'. Any city or county which requirese permit toconstruct.alley,also
improve, demolish, or H., vo any structure, Prior ne its issuance, also
for liner permit t0 file 'v signed statement that
he is tic thedp pursuant
he is licensed pursuant n the provisions o the700 Contractor's License
of Division 3 of the
Law (Chapter 9 (commencing with Section is exempt
Business and Professions Code) or that he is exempt echo 70 and
the basis for the alleged exemption. Any apiplicn of Section 703L5
by any aorei thaary fore permit dollars the 0).): amToacivil penalty
of not more than five hundred dollars (550emp
❑ t as owner at the property, or my employees with rugs, ax
their sole compensation, will (S the work, and the structure is not
and Professions
intended or offered is sale (Sec. 7044, not
Code: The Contractor's License Law does not apply to an owner of
apply
property who builds or improves thereon, and who does such work
himself or through his own'emph,yev, , provided that such improve-
mentsarenotintendedorofferedforsale. If. however, the building
Or im Provemmril is sold within one year of completion, the owner -
builder will have the burden of proving that he did not huild or int-
of sale.).•
prove fors own
❑ t as owner o the property, he exclusively .7044, contracting with
licensed contractors to construct the project La does Business
and Professions Code The Contractor's License Law does not apply
to antr owner of Property who builds tr improves thereon, and who
contracts actor's h projects with a ContratOHsl licensed Pursu:utl to
License Law.
the Zany exempt
❑ lam exempt under Sec ,B.&P.C. for this
reason
TEMP. POLE 30.00
BUILDING P RMIT
INFORMATION
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTR. UC. NO.
ELED.
TOTAL
PERMIT TO
/
QTY. PLUMBING PERMIT FEE
S S
YPE CONSTR.
ALTER -DRAIN -WATER IEA.) 5.00
BACK F LOW PROTECT. DEV ICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, GOND. 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
❑ PES I❑ ❑ o�r
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
- ASSESSORSPARCEL NO.
LAWN SPRINKLERS - OVER 5IEA.) 1.00
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
Owner Date
W'ORKERS'COMPP-NSATION DECLARATION
1 hereby Affirm that 1 have a certificate of consent tD self -insure,
or a cetlilicate of Workers' Compensation Insurance, or a cerlilied
copy thereof (See, 3800, Lab.C.).
Policy No. CO;TIj Y
❑ Ce died c y Is hereby fur -
❑ Ce ifled c y is Iedllwrfh he c nspe�ctio�n `divisi�on
Appliwm L 4+
Qi f ATE Op P- EMPTION ,0M WORKERS'
COMPENSATION INSPRANCE
(This ion need not be complet J it the permit is for one
hundred dollars IS, 00)
S100) or. lex,
I certify that in 0m performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensul inn Laws of California.
Date ApplicmR
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
ZONING
ENG, SITE NO.
FIRE SPRINK
Y ❑ N
ENERGY TZE
Y ❑ N�
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y E]N❑
A. L.I.C.
Y [3NE]
PLG.CONTR. LIC, NO.
PLG.
TOTAL
QTY MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 5.00 -
NOTICE '10 APPLICANT: It after Raking this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
,yell provisions or this permit shall be deemed revoked.
CONSTRUCT ION LENDING AGCNCY
I hereby affirm that there is a const,oclion lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.CJ.
Lender's Name
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10)000CF.M.) 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT(OVER I0,000CEM.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lenders Address
HEATING UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
I certify shut I have read thisapplicatimt and state that the above
infornalion ix correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
herebythis city to enter upon the
hereby authorize representatives for
inspection purposes.
antioned property forinsp of
(We) agree to save, indemnify and keep harmless the City of
Cupersin aglli t liabilitiga-j costs and expenses which
may any wu a Ne o'' said sty in Vmsequence of the
Starving it tris p mit
Signatu a / ntracto ate
VENTILATION FAN (SINGLE) 4.00 ry
-
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
PLUMBING
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
1
/ / t INSPECTOR COPY