C8596 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
FE
I NG PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
SO W01-AE �y) BUILDING - ELECTRICAL-PLUMBING-MECHANICA 8596 PLAN CHECK VALIDATION
,1 /Cox,
� PEIVNEL OTY. ELECTRIC PERMIT FEE
IvnoNECONT
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
NAME NoMLi sPelrJkl.�e JI LIGHTING FIXTURES 10.00/1.00 L
CONTR
C.NO.
ADDRESS
Cro s1`4 APPLIANCES-RESIDENTIAL 4.00
III T Aooness IO?6U NL�W AU�
/er ONE PANELS 10.00 DATE OF APPLICATION
ORRCRITEC t PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.NO, SIGNS TRANS, j 3.00' .
ADDRESS ENG. CIRCUIT I 5:00 PERMIT vac OanoN
ZIP fTEMP.METER OR POLE INS.'., '>IF20.00
ADDRESS s MOTORS SEE FLEE SCH.
SERVICE CHANGE 20.00
w o o LICENSED CON'I'RACiORS DECLARATION TEMP.POLE 30.00
<U I hereby affirm that I am licensed under provisions o'Chapter 9 s ISSUA CE 0/ATE
n "' Icommencin wish Section 7000)of Division 3 of the Business and
¢ H g BLDG. ELECT. PLG. MECH.
H N z Professions C. and my license is in full force and effect, ❑ ❑ ❑ ❑
Z
o m - License Class Lic.Number
9 H D ,Dale Contractor_
¢ y f BUILDING PERMIT
¢ ao ac
ce o OWNF;R-BUILDER DECLARATION INFORMATION
wLL I- I hereby affirm that I am exempt bruin the Contractor License MISC.- REFER TO ORD
Hu0J Law for the following reason.(Sec.7031,5,Business and Professions PERMIT ISSUANCE 10.00 'VALUATION $/FT.
wr Code:Any city orcounty which requires a permit to construct,alter, 77 QQ ��rF�
Q Q ¢ 2 improve,demolish,Dr repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
G B, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License -
r T a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe .
i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE � w7
Ie H es the basis for the alleged exemption.Any violation of Section 7031.5 STO IES YPE CO TR.
e- 3 m by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(S500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ I,as owner of the property.or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP REE.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,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
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 employees,provided that such improve-
memsarenotintendedorofferedforsale.Il',however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA ) 200
builder will have the burden of proving that h - . - . .
u did not huild or ice- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON pa Omer
❑ 1,as owner of the property,am exclusively contracting with El 0 El Q 0
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.8. 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-OVER 5(EA.) 1.00
contracts for such projects with a contmctorts)licensed POralmmt to
the Contractor's License Law. SEWER-SANITARY-STORM V-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
O 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.
WORK ISRS'COMPIiNSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a Certificate of Consent to self-Insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy threcof(Sec,3800,Lab.C.).
Policy No�,�q�g Company�.�����.�.
❑ CerRllPo, *1y is herb fu Iahltl FIRE SPRINK ENERGY T"24
z Z ❑ Cert cu is l nigh(the rte, division. MISC.- REFER TO ORD.
O Applican � et���/e/ _ - YE] NE] YE] N❑
CCT PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
LU CE EXEMPTION FROM WORKERS'
LU tied not
INSURANCE PLG.CONTR. LIC.N0, PLG. Y� N Y ❑ N❑
Z) (I hi, section Iced not be completed if the permit is for one TOTAL
lumdred dollars 1 S 1001 or less.) •
U O I 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
oU become subject to the Workeri Compensation Laws ofCalil'ornla. BUILDING
d D:dc Applicant ALTER OR ADD TO MECH. 5.00
} an NO'I'ICI. T '
O APPLICANT: 11',after making this Certificate of F-x-
H ? emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with Q 3
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10/100C.F.Ii 4.00 FEE /o 3 _
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10)M0C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perl'ofmance of the work for which this permit is issued tSer. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
Icertil'y that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
ordina ccs n correct. 1 ague to comply with all city and county and PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over t00,0008TU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. �-
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cup,dino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting of this permit MECH.CONT. LIC.NO. MECH.
�, TOTAL TOTAL
S" t real' pplcnt/C rudtor [)are
INSPECTOR COPY