18612APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT IDENTIFICATION -
APPLICATION &PERMIT_
BUILDING- ELECTRICAL- PLUMBING - MECHANICAL
.PERMIT NUMBER
O C 1
OO I
BUILDING
AODR-,s o � /�e
OW NEN
NAME�� QO &8/ I�
I/�1 /T
ONE
Y. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTOR'S
NAME��('
LIE. No 7
OUTLETS-SWITCHES-RECEP 10.00/1.00�`�w�.l
LIGHTING FIXTURES 10.00/1.00
CONT R/cTOR'
ADDREs��
Y
PXO
PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENG.
ZIP
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
-.
ISSUANCE DATE -
EMP. METER OR POLE INS. 20.00
noxa ss TS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 -
LICI;NSE DCONTRACTORS DECLARATION
1 hereby affirm that 1 an licensed under provisions of Chapter)
(commencing with Section 7000) of Division 3 of the Business and
Licens,fJi Codi, enre is DID[ to f
Liccnsc ss_ "y Con Numhc� �
Date �n� ` Contractor
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Law for ilia following reason. (Sec. 70315, Businessand Professions
Code: An cit orcoum
Any y y it my structur e permit t o construct, also
prior to its issuance, also
improve, demolish, or repair any permit
requires the applicant for such permit to file i signed statement that
I. file
Ile is licensed
hSecti n 00 )ofDICtOIS 3 oft Se
apte 9(comlto the with
Law (Chapter Y (commenting with Section 7s cev of Division 3 of Inc
Business and Professions Code) or that he is exempt therefrom and
031.5
by!myisfolthe icanaora exemption. Subjects
by any applicant fora permit subjectslhe0R.): anttoacivil penalty
tsthAny eapplicant
plica ofoaCion malty
of not more than five hundred dollars (my employees
❑ Las owner of the properly, or my employees with wages as
their sole compensation, will Jo the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsare Ill intended or offered for sale. If, however,ihe building
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that lie did not build or im-
Time for purpose of rale.).
❑ 1, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec 7044, Business
and Professions Code: The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon, and who
contmcls for such projects with a conlractons) licensed puraudnt to
file Contractor's License Law,
❑• lane'exempt under Sec ,B.&P.C. fix this
rCasOn
BLD
ELECT.
❑
PLG. MECH.
❑ ❑
BUILDING PERMIT
INFORMATION
MISC. - REFER TO OR
PERMIT ISSUANCE 10.00
VALUATION
�
$/FT.
ELEC. CONTE, LIC. NO.
ELEC
TOTAL-
PERMIT TO
,
-
QTY. PLUMBING PERMIT FEEthe
ALTER-DRAIN-WATER(EA.)5.00
STORIES
TYPE CONSTR.
BACK FLOW PROTECT. DEVICE 4.00
OCC, GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
GAS - EA. SYSTEM -OVER 4 -(EA.) 2.00
BUILDING USE
RE IND C ry Q OOr
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSOR PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATERHEATER W/VENT 6.00
Owner Data
WORK ERS'COMPF-NSA'IION DECLARATION
1 hereby affirm that I have a earl ificate of consent toself-in vase.
or a certificate of Workers' Compensation Insurance, a certified
copy thereof (Sec. 3800, LithC.)��/l.•sin Tf/
Policy N r( ooh cb
❑ Ccrtite shcrehy l'un had. `iI' inn ivirio
�`�1,.s,, Cerlifi� r Id l til n
AI'0'Icdnt 1C1
WATER SYSTEM - 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
ZONING
ENG. SITE NO.
F A
FIRE SPRINK
YO N,El
ENERGY T24
Y❑ NEI
MISC.- REFE TO ORD.
CERTIFICA'r'Ii OF EXEMPTIONF OM WORKERS'
COMPFN$ATION INSURANCE
This .dollars need not be completed it the permit is for one
hundred dollars 151001 or less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall nut employ any person in any macre, so as to
become subject to the Workers' Compensation Laws of California.
Dat` am -
NOTICE TO APPLICANICAN T: If, after making This Certificate o1' Ex-
enl Piiml, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must 1'orihwilh comply with
such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
Ilia performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
Lender's Name
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y N�
A.L.U.C.
V ND
PLG. CONTE, C.
Q
)IOTA
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
,�r
61L0
ALTER OR ADD TO MECH. . 5.00
APPLIANCE 5.00
PLAN CHECK
FEE6L
R5
AIR HANDLING UNIT (TO 10=C.F.M,) 4.00
AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITHDUCT) 5.00
MICROFILM
�-
G UNIT (TO 100,000 B.T.U.) 8.00
Lender's Address -
I ceitify that lleave read this application drill state tat the aboveATION
is eorrnct. 1 agree to comply Willi all city and countyCOMP(3
doll state laws rlating m building constroCtion, andhereby inwhic r11e representative, of this city to Enter apso, tile'above-mentioned property for inspection purposes.
agree to save, indemnify and keep harmless the City ofREFER
ain,t liabilities, balgmenm, costs and expanses whichCONST.
lay a way ace a against said City in consequence of theISSUANCE
t f hi perm)
ign of ppli / o true r Uate
G UNIT(OVER 100,000 B.T.U.)9.50
ELECTRIC
FAN (SINGLE) 4.00information
H.P. or 100,000 B.T.U.) 6.00PLUMBINGordinances
P("TO'00
-COMP (Over 100,000 BTU) SEE PEE SCH.
MECHANICAL(We)'
TO ORD:upertino
10.00�m
TAX
LIC. N0.
MECH.��TOTAI
TOTAL
Z%2
• OFFICE COPY