8723 (3) a�w•
APPLICAjJrTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
- /' BUILDING PROJECT lDENTIFICATION PERMIT NUMBER
X
So LONG APPLICATION & PERMIT
8723
ADDRESS
B ILDING -ELECTRICAL-PLUMBING -MECHANICAL
PLAN CHECK VALIDATION
NAME ('7 /(�/� OTY. ELECTRIC PERMIT FEE
PHON[�iJ I {�//V
NAME domi'AcoORs UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDR FSS AcraR's APPLIANCES-RESIDENTIAL 4.00
ADDRE
PHONE PANELS 10,00 DATE OF APPLICATION
ARRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.Na.
ENGINEER
LIC No. SIGNS TRANS. 3.00
ARCH ErvG. �T+ '41`�-,, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS 55
ZIP TEMP.METER OR POLE INS. 20.00
APPLI MOTORS SEE FEE SCH.
ADDRESS
55
SERVICE CHANGE 20.00
o o LICENSIiUCONTRACTORS DECLARATION TEMP.POLE 30.00
a
rca o I hereby aflion that I aur lironsed under provisions oI Chapter 9 ISSUANCE DATE
Z w (commencing with Section 70001 of Division 3 of the Business and
¢ a BLD ELECT. PLG. MECH,
w i Professions Codc,and my license is in(salt force and effect.
2 O m - License Class Con Numbractor )
O m H� Dote Contractor
BUILDING PERMIT
¢ a OWNER-BUILDER DECLARATION.'
K oINFORMATIONION
w 3 cw 1 hereby affirm that I am exempt from tire Contmetor's License MISC.- REFER TO ORD
LL LL o j Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires a permit o construct,atter,
re improve,¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
n m¢ squires the upplicant for such permit to file a Signer)shtanent that TOTAL PERMIT TO
ce he is licensed pursuant to the provisions of tire Contractor',License
r z.i
Law(Chapter 9(commencing with Section 7000)o1'Division 3 ofthe
- a Business and Professions Code)or that he isexen,pt therefrom and OTY. PLUMBING PERMIT FEE
E x o
xFo the basis for the allegedtexemption.tst applicant
to action malty STORIES TYPE CON TR.
dam by any applicant fora hundred
subjects thSOO).)canuoacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundreJ Dollars(5500).7:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 oCCGROUP EES. s
their sole compensation,will do the work,and the structure is not .
intended or offered for sale (See, 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,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 SG.FT.FLOOR AREA TOTAL ACREAGE
himselfre throughhissawnemred for Providedthatsuch improve-
ments
mprov
mcrosare through his
ot own
it employees.
sa le.Iided that suhebuildingmproe- GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
build r will have❑m harden of proving that he did not build or ins- BUILDING USE
pr v for purpose Tl Saltj. INDUSTRIAL WASTE INTER. 30.00 REs IND Co Pa 011
I,as owner of the properly,am exclusively contracting with ❑ ❑ ) ❑ ❑
I' en d contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS- 1 INC 5 V.8. 6.00 ASBESSO P RCEL NO.
nd Professions Code:The Contractor's License Law does not apply
'to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
contracts for s ch projects wf. ,' a ntmCrops)licensed pursuant to
the Contm-o iceme . SEWER-SANITARY-STORMEA.200ft/10.00 TRACT NO, PARCEL NO.
❑ Ins c tend• C. BAP.C. ort WATER HEATER W/VENT 6.00
reason
Owner Dm' WATER SYSTEM 5.00
Y ACC.DATE ACC.FILE N0.
/\ 'ORKERS'COMPhN ON 'LARAT N WATER TREATING EQUIP. 5.00
I hereby affirm that I ha icer fc of mount to self-iasure.
or a certificate of WorkersCo nsation Insurance,or a certified ZONING ENG.SITE NO.
copy therfof(Sce.3800,La .).
Policy No. Company
O ❑ Certified copy is hereby firnished.
FIRE SPR INK ENERGY T-24
Z Z ❑ Certified copy is fdeJ with the city inspection division. MISC.- REFER TO ORD.
p Applicant v ❑ N❑ v ❑ N❑
CERTIEICA"Ili Oh EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.UC.
W > C0h1PFNSA'IION INSURANCE: PLG.CONTE. LIC.NO. PLO.
(Phis section need not be completed if the permit is for one TOTAL Y❑ N❑ Y E] N❑
Z
hundred dollars IS 1001 or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
kL I- mit is issued. I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California.
y Date Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING SU
} w NOTICE TO.APPLICANT: If,after making this Certificate of Ex-
♦- Z emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U .such provisions or Ods,..olt shall be deemed ,vokvd. AIR HANDLING UNIT(TO I0=C.F.M.) 4.00
CONS"FRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE AA
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(Sec. MICROFILM
3097,Civ.0 T HEATING UNIT(TO 100,000 B.T.U.) 8.00
cder's
Lenuder's Address HEATING UNIT ER 100,000 B.T.U.)9.50 ELECTRIC
L
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct I agree to comply with all city and county PLUMBING
ordinances and slate Incas relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby en I)tied
roper y tat iins of this city to enter upon the BOILER-COMP 1Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-men mod property for insp of
purposes.
(We) g a to save, ' em 'fy and keep harmless the City of MISC.- REFER TO ORD.
Cuperti 'gains( liab' s, gments, costs and expenses which CONST.TAX
may i a ay ac ast said City in consequence the PERMIT ISSUANCE 10.00
grant g is MECH.CONT. LIC.NO. MECH.
a 9 TOTAL TOTAL
am ontr t,r ate
INSPECTOR COPY
I