C8710 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
-s. BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
BUILDING APPLICATION & PERMIT
A�oeq� �v�« � . 8710
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S '/� LAN CHECK VALIDATION
AkKF-k UA-RILESh orvE���`�y TV. ELECTRIC PERMIT FEE
NAMERAc.oRs UTLETS-SWITCHES-RECEP 1&60/1.00 S--
uc.NO. LIGHTING FIXTURES 10.00/1.00
AD
CONTRACTOR PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
OgcerrecT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
END W EER
LIC.No, SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 �J
AANT'S
ADDRESS MOTORS SEE FEE SCH. l.•
DRESS EES
SERVICE CHANGE- PAM
w W o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 �J
a o u I hereby affirm that I ani licensed under provisions of Chapter 9 JUL I j ( [ ISSUANCE DATE
v, w (commencing with Section 7000)of Division 3 of the Business amt
a Professions BLDG. ELECT. PLG. MECH.
H Z Professions Code,and my license is in full force and effect. v ❑ ❑
Z o y License Class Lic.Number
o w H w Date Contractor City of Cupe 'no
BUILDING PERMIT
¢ ¢o i OWNER-BUILDER DECLARATION INFORMATION
wS v I hereby affirm [hat I am exempt Cann life Contractor's License MISC.- REFER TO ORD
H u o v, Law for the following reason.(Sec.7031.5,Businessand Professions pERM1T ISSUANCE �.� _� vA �A///TEELIO1IND $/FT.
rA0 Code:Any city or county whichrequiresa pennittoconstruct,alter,
ac a a improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR. LIN
C. O. ELEC. UL/1lTV'T
wO u requires the applicant for such permit to file a signed statement that TOTAL ti PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License �•
Law.(Chapter 9(commencing with Section 7000)ofDivision 3 of the
a Businessand Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
sio
¢ H m the basis for the alleged exemption.Any violation of Section]031.5 CS7pglr SxTYPE CONSTR.
d3 � by'any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 ta119U lr U petino
of not more than Dve.hundred dollars(5500).):
❑ 1,as owner ol'the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sea 7044. Business and Professions DRAIN$-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 SQ.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such im building
, hients mself a through
ot or offered employees.
or provided that sthebuilding GAS-EA.$VSTEM-l1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
RES' IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ d as owner of the property,he exclusivelyoor (Se contracting with
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL No.
and Professions Code The Contractor's License Law does not apply
to tr owner of property who builds or improves[hereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such pEnw with a contracted s)licensed pursuam to SEWER-SANITARY-STORM EA.200ft/10.00
the Contra r i License aw TRACT N0. PARCEL NO.
❑ I W exempt under- BAP.C.far ilii. WATER HEATER W/VENT 6.00
so
x na
Ow Dat' WATER SYSTEM 5.00 ACO.DATE ACC.FILE NO.
WORKF.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm (hat 1 have a certificate of consent to self-insure' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereuf(Sec.3800,Lab.C.L
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z 2 ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
V Applicant Y ❑ NE] Y ❑ IN
y CERT1171CATI:OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 .FLOOD ZONE A.L.U.o.
LU > COMPE:NSAT'ION INSURANCE PLG.CONTR. LIC"NO. PLG YE] N� Y � N�
EL Z (This section need not be completed if the.permit is for one. TOTAL
hundred dollar,($100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
U. I- mit is issued,1 shall not employ any person in any manner so as to
UV become subject to the Workers'Compensation laws of California. ��•
Go Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} va NOTICE TO APPLICANT: If,after making this Certificate of fix-
I.- 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE ?Q-
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
AIR HANDLING UNIT 10MOC.F.M.) 6.00 SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 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"CL HEATING UNIT ITO 100,000 B.T.U.) 8.00
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I 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 state laws relating In building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
herehv authorize representatives of this city to enter upon the BOILER-COMP )Ove.100,000 BTU)SEE FEE SCH. MECHANICAL
abovs mentioned property for inspection purposes.
(W.j agree tosay,, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Caper ino against li ilit ies,judgments, costs and expenses which CONST.TAX
O�l�gl(��.YfApappy'l.rj.�lr/"Cont,.C,.,wC ` against sai ry in consequence of the PERMIT ISSUANCE 10.00of this MECH.CONT. LIG NO. MECH.
OTAL TOTAL ate r
OFFICE COPY