13565 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' BUI VDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT A ��^
ADE I b
G+ BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
WNoE 'S
L PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
•I ' C PHONE
CONTRACTORS
IUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. IY9132Z 1LIGHTING FIXTURES 10.00/1,00
c.141.AGTOR's PPLIANCES-RESIDENTIAL 4.00
ADDRESS
7O0eONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT`_ '' �yS2o. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR J J //
ENGINEER
LIC.No. ISIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 � IV/N✓4.NJ/
woo LICENSED CONTRACTORS DECLARATION o
a v I hereby affirm that I am licensed under provisions of Chapter 9 J w CI ISSUANCE DATE
Q vAi (commencing with Section 7000)of Division 3 of the Business and \ 1,1 G. ELECT. PLG.•' MECH.
is Professions Co d license is in full for `e(fec Z
I_uO Y Is\ '\ Er
z 0 y- License Clas_ sL.�=.G�Lic.Number ❑ t� ❑
O ,F aa Date '_Trb/q{E7ntf�' Contractor L
: m f 's(j "BUILDING PERMIT
M x w WN -BUILDER DEC A I INFORMATION
E o I. s- I herebyaffirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
P VALUATION $/FT.
111 3 0 a Law for the following reason.(Sec.7031,5,Bunnessand Professions PERMIT ISSUANCE 10.00
- o Code:Any city or county which requires a permit to construct,alter,
2
a ,p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
y c, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
e w m he is licensed pursuant to the provisions of the Contractor's License
F z Q
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 OHIEG TYPE CONSTR.
u ;m by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sale compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 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 build's or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 50.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-1 8.00
meats are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- SYSTEM-EA.SVSTEM-OVER 4 (EA2.00 BUILDING USE
builder will have the burden of proving[hat he did not build or im- RES IND CON Pe Other
prove for purpose ofsale.). - INDUSTRIALWASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec ,B.&P.C.fur this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent Io self-inwlre• ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
❑ N❑ V ❑ NEI
CC CERTIFICATE OF(EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.•
L COMPENSATION INSURANCE PLO.CONTR. LIC.NO. PLG.
(L O (This section need not be completed if the permit is for one TOTAL Y❑ N Y❑ ❑ N❑
=) Z hundred dollars IS 100)or less.)
U O I certify that in the performance he work fy hich[his per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ a he it d mnner so as to
Q W becorp�ubj Workers'C pensali fi s California. BUILDING
0. Date - �pPo, I ALTER OR ADD TO MECH. 5.00
} N NOTItf.T'( AP L CANT: I , ler ma eII 6 lis Certificate o x-
F Z emplion,you should become subject to the Workers'Compensation APPLIANCE ..�1 5.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNITZ(T04(;PMC-F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 104M C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(+NITH'DUCT) s Q 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT O'100,000`B}TiU.) 6.00 MICROFILM
3097,Civ.CJ.' (T
Lender's Name HEATI NG UNIT(OVERg100;000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that 1 have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or 100,000B.T.U.) 6.00 n //
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,00)BTU)SEE FEE SCH. MECHANICAL pC10%
above-menti property for inspection purposes.
(We) tee save, indemnify and k rmless the City of MISC.- REFER TO ORD.
Cupert' o a list I'' i' ies,judgments and expenses which' PERMIT ISSUANCE 10.00 CONST.TAX
may a way c e ainst said in consequence the
gran n f this p t. / N MECH.CONT. LIC.NO. MECH.
12 Qg� 7f
TOT
a� oa TOTAL a�_!�O-
ureal picant/Contract Date
OFFICECOPY