8692 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PENIONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
7( Ao' oFIN APPLICATION & PERMIT
BUILDING- ELECTRICAL-PLUMBING -MECHANICAL 8692
OwNER'S VV PLAN CHECK VALIDATION
NAME OTV. ELECTRIC PERMIT ' FEE
QnVPHONE^ L 1
CONTRACTOR5
NAME C'10 OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S pPLIANCES-RESIDENTIAL 4.00
ADDRESS y1�,�(�
• P11YIrADNE PANELS 10.00
T PLICATION
NA ITECT PANELS (OVER 200 AMP) 20.00 PLA HECK'. P. NO.
ENGINEER
LIC.No, SIGNS TRANS. 3.00 �
ARCH OR ENG. SPECIAL CIRCUIT 5.00 PE I V ION
ZIP EMP.METER OR POLE INS. 20.00 L`I Uf,Cupert�fl0 J
-APPLICANTS MOTORS SEE FEE SCH. 'City,
ADDRESS J
SERVICE CHANGE 20.00ar f
•,�o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 rte/
a i u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H m i I'mfcsgmo Code,and my license is in full force and effecL ❑ ElElO i m 'License Class Lia Number
H n H J Dale Contractor
a y f BUILDING PERMIT
Q rca OWNER-BUILDER DECLARATION
a o aU INFORMATION
w g LL N 1 hereby affirm that I am exempt from lire Contractors License MISC.- REFER TO ORD
u O a, Law for the following reason(Sea 7031.5.Businessand Pmlcssians VALUATION $/FT.
- PERMIT ISSUANCE 10.00
Su;w Code:Anycity or County which requires a Pcrout to construct,alter,
j R , a O improve,demolish,or repair any structure,prior to its i suance,also ELEC.CONTR. LIC.NO. ELEC'
d w0 ae requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
es y he is licensed pursuant to the provisions of the Contractor's License
Hz > Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE AA
¢ F$ the basis for the alleged exemption.Any violation of Section 703 L5 STORIES T ECONSTR.
a ; _ by any applicant for a permit subjects tb4 applicant to civil penalty ALTER-DRAIN St VENT-WATER (EA.) 5.00
of not more than five hundred dollara(S500).1'
❑ I,as owner 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(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Code:'flier Contractors License Law does not apply to an owner of
property who builds or Improves thereon,mid who does Such work FIXTURES-PER TRAP 5.00 SO VT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such Improve-
mentsare net intended oroffered for salt.IL however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,IIIc Owner- GAS EASYSTEM OVER 4 (EA.) 2DD BUILDING USE
builder will have the burden of proving that he did not build or am- - . - . . RES IND CON PB Omer
prove for purpose ofsale.)' INDUSTRIAL WASTE INTER. 30.00
.- ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct tire project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
and NO.
and Professions Coda:Th
e Contractor's License Law docs ,of apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contramorl s)licensed pursuant m SEWER-SANITARY-STORM EA.2001t/10.00
the Contractor's fos License Law. s TRACT NO. PARCEL N0.
❑ I am 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.
WORKERS'COMPFNSAT1ON DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a Certificate of-consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy NmreoflSee.3800,Lab.C.L 1
Policy N0.7."1„ey_E(.•js�pany y.
�•y p AM, 'a
O ❑ Certified copy is hereby furnls m -`
Z ZCertified copy is fled will, the city inspection division. FIRESPRINK ENERGYT24
O . p ranit MISC.- REFER TO ORD, y ❑ N❑ v ❑ N❑
C w CERTIFICATE OF:EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU CO,\IPCNSATION INSURANCE: PLG.CONTR. LIC.NO. PLG.
CL O' (this Section need not be completed it the permit is for one TOTAL y❑ N❑ Y ❑ N❑
::) Z hundred dollurs($100)or less.)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as 10
O W become subject to the Workers'CompensaTion Laws of California.
D, Date Applicant ALTER OR ADD TO MECH. 500 BUILDING
>_ m NUrICI>'T0 APPLICANT: IF,atter making this Certificate Of Ex-
.
I.- 2 eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 i PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
MFEE
U h provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOC.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(SeeMICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
ordinances is rotate[. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws relating c to comply
with const met inn• and
hereby authorize representatives of lhis city to IT upon the BOILER-COMP (Over 100,000 BTU1 SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
agree to save, 'nd- and keep harmless the City of MISC.- REFER TO ORD.
uperl' ainsa liabi s,judgme its, culls unit expenses which PERMIT ISSUANCE 10.00 CONST.TAX
LOS In any way C e against sa' City in consequence of the
Lain I MECH.CONT. LIC.NO, MECH.
TOTAL TOTAL
1 gnus of phenol ontractor Dutc
INSPECTOR COPY