C6287 d APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PER IT NUMBER
aUILDING APPLICATION & PERMIT /�
ADDRESS 6 Z 8 7
E, q L fU6 G BUILDING -ELECTRICAL-PLUMBING-MECHANICA UG
OWNERS (ff, xl-;-p�LGrn P LAN CHECK,VALIDATION
• Q5 •T��GP� - QTY. ELECTRIC PERMIT FEE
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00 ✓•�-� Ste'
NAME
' uc.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00 'S '` ✓L
V Ao
7` oREss `(� I YUON �3^I05Z� PANELS 5.00 DATE OF APPLICATION
ARCHITECT r 1 'i , `^Ob�I SIGNS 3.00 PLAN CHECK FEE P.C.NO.
I- s' �^ LIC.N SIGNS TRANS. 3.00
ARCR.OR INC, I PRIM{�E WAf.I SPECIALCIRCUIT S.00 PERMIT VALIDATION
AQDHESs P
Q TEMP. METER OR POLE INS! // 15.00
APPLIGA 's MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
• Foo\ f' LICENSED CONT'RACT'ORS DECLARATION
u.6 1 , I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
t a N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H�0 z Professions C,'"y1�' uul my license ism full fur' and of ' ( ❑ ❑ ❑
z o m - License(:IaUq se Lia tractor l� _-(la - YJ
0 0 F Dale ,�QY1 b��}_Contractor
a y E -- BUILDING PERMIT
p'w a OWNER-BUILDFR DECLARATION INFORMATION
AOA " MISC.- REFER TO ORD
'ca 3 r I hereby collo That 1 am exempt from the inestaeror's License
U.
Law lot the following reason.(Sce.70J1.5,Eusinessand l'ro(essions VALUATION
F _ PERMIT ISSUANCE 6.000 Code:Any /� '•-�
improve,demolish,
countywhich
requistmmm permit ttoconsuance,also CQ' ;
QQ¢ 0 IIt111rOVe,dl'InOI11 h,Or fCpall any flmetuRl.pl101 to IIS ISSpallCe.also ELEF CONTR. LIC.NO. ELEC. E (!
E m LL mquires the applicant for such permit to file a signed statement that .y -
u w he is licensed pursuant to the provisions of the Contractor's License
F z < Law.(Chapter 9(commencingwith Section 7000)of-Division 3 ofthe
n
4 O Ijusiness and Professions Code)or that he is exempt therzfrom and QTY. PLUMBING PERMIT FEE
1- aN m basis for the alleged exemption.Any violation of Section 7031.5 TDRIE P C R.
- by any applicant lot a permit subjects(lie applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not mom than five hundred dollars($500).):
❑ I,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 st recture is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
.Code:The Contractor's License law do ,not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.PT FLOOR AREA TOTAL acREaeE
himself or through yrs own employers,provided that SOCK improve- 4
ments are not intended or offered for sale If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OV ER 4(EA.) 1.0 BUILDING USE
builder will have lire burden of proving Nlxt he did not build or im- IND CON PB ,Other
prove for purpose of sale.). INDU TRIAL WASTE INTER. 20.0
���• ❑ I,as owner of the progeny,am exclusively contracting with ❑'. ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAW NIS PR I N KLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts lou such projects with a contmctuns)licensed pursuant to
lite Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
1- - mason
owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK I*RS'COMPENSA'1'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that l have a cenificalcofeonunl la wIfi..mrr' ZONING ENG.SITE NO.
/ or a certificate of Workers'Compcnselion Insurance,or a certified
copy Ihereof t els.3800,Lab.(:
P I No. Compan .-
1/J Ccnilie py ish fun' Ir H FIRE SPgINK ENERGY T-24
t Z Z �5L1 rtifekd 'a 'd c' inspection division. MISC.- REFER TO ORD.
I, O Apflican��l-_ Y❑ N❑ V❑ N❑
�( 2 rn _-i4.R'f0'ICATF.OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
r
1 LU 5; 1 COMPIMATION INSURANCE PLG.CONTR. LIC.NO. PLG. ❑ N❑ V❑ N❑
Fd O (Phis section red not be completed if the permit is for one TOTAL 6 V
:) Z hundred dollars IS 100)or less.) ��yy
_U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT St FEE FEE SUMMARY
' IL F- mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
a Dam Applicant % ALTER OR ADD TO MECH. 4.00 BUILDING 00
} to NOTICE 10 APPLICANT If,after making this Certificate of E,,_
F_ Z caption,you should become subject to the Worken'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this pundit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCIFIONLENDINOACENCY AIR HANDLING UNIT(OVER 10;MC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction Inuring agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permitjis issued(Sec MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Na
Adde HEATING UNIT(OV ER 100,000 B.T.U.P.50
Lmterrs Adder:: ELECTRIC -53
-
I certify that I have read this application and at that the above VENTILATION FAN (SINGLE) 3.00 `'
information is correct. I agree to comply with all city and county PLUMBING
ordinanb
ces and stale laws relating to uilding'construelion, and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 4.00 a
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000 ETU)SEE FEE SCH. MECHANICAL ,7
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
_ Cupp inn againstfliabilities,judgments, costs and expenses which PERMIT ISSUANCE ' 3.00 CONST.TAX
ma�1 any way a crus ug nsl said City in consequence of the 7
goon' golf rsPum it MECH.CONT. LIC.NO. MECH.
' ed 'Date' " TOTAL TOTAL 3e 7/
Sign rl of plica tConfractor Date
INSPECTOR COPY