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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- US
,,FBALL POINT PEN ONLY
" BUI LDI NG PROJECT I DENTI TION
APPLICATION & RMIT
BUILDING - ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
11235
AUIL ENG
ADDRE ss
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NAM, . �='1K-
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(3e_0d I:A_ A!`�(�L PHONE J'
QTV. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION -
DATE OF APPLICATION
CONTRACTORS
N ME
\ LIC.No ,219LIGHTING
UTLETS-SWITCHES-RECEP 10.00/1.00
FIXTURES 10.00/1,00
ADDRESS offs Mill P1� -
CONTRAS 1 /�
iqL1y v PHONE (�(� (/y
PPLIANCES- RESIDENTIAL 4.00
PANELS 16.00
ARCHITECT
OR
ENGINEER
LIC. NO
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
ISIGNS TRANS. 3.00
ADDR.SS ENc'
ADDRESS
SPECIAL CIRCUIT S.QQ
PERMIT VALIDATION ,
EMP. METER OR POLE INS. 20.00
ZIP
Ifu/ALIDATII
APPLICANT'S
ADDfl E55
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
PAI& /y -1L
I
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
HillSU N 9ATE
(commencing with Section 7000) of Division 3 of the Business and
ELEC j !;PLG. MECH.
Professions Code, and my license is in full force and effect.
License Class Lie. Number
❑ ❑ ❑ ❑
Date Contractor
EI MIT
OWNER -BUILDER DECLARATION
I herebyaffirm that I am exempt from the Contractor's License
P
Law for the following reason. chregires 5, Businessund Professions
Code: Any city or county which requirese permit to construct, alley,
improve, demolish, or repair any stnmture, prior to its issuance, also
ON
INFORMATION
MISC. - REFER TO ORD
VALUATION
/O
/
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC.
requires the applicant for such permit to rite a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
TOTAL
�A PERMIT TO
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation oTSecliun 7031.5
x.L /'L 0�-1J/� 3
STORIES13
ALTER -DRAIN -WATER (EA.) 5.00
by any applicant for a permit subjects the applicant toacivil penalty
of not more than five hundred dollars ($500).1:
❑ 1, as owner To the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended of offered for sale (Sec. 7044, Business and Professions
BACK FLOW PROTECT. DEVICE 4.00
OCG. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
Code: The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon, and who docs such work
F IXTUR ES - PER TRAP 5.00
sO. FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided Ilial such impoc ve-
mentsarenotintended or offered for sale. If, however, the building
GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion, (lie owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to Construct ole project (Sec. 7044, Business
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Ouher
1:10 El❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
and Professions Code: The Contractor's License Law docs not apply
to an owner of property who tips or improves t aeon, and who
LAWN SPRINKLERS- OVER 5 IEA.) 1.00
contracts fo such projects wit contractou s) li nsed pursuant tO
the Conn. t 's Lica Lew
SEWER-SANITARY-STORMEA.200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
❑ Ia pf der5 , 13AP.C. for this
-Z.,
eason
x Owner Do
WATER SYSTEM 5.00
ACC.DATE
ACC. FILE NO.
WORKERS'COMPENSATI EC ATION
WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lub.C.).
Policy No. Company
❑ Certified ropy is hereby furnished.
❑ Certified copy is tiled with the city inspection division.
Applicant
FIRE SPRINK
Y ❑ N E]V
ENERGY T 24
C]N[]
MISC. - REFER TO ORD.
OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10,00
FLOOD ZONE
A.L.U.C.
PLO.CONTR, LIC. NO,
PLG.L
TOTA
COMPENSATION INSURANCE
section need not be completed if the permit is for one
V❑ N❑
1 NN[3(This
MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollms($100) or less.)
I certify that in the performance of the work for which this perOTY.
mit is issued, 1 shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Date Applicant
BUILDING
pp
Ido i
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should became subject to the Workers' Compensation
APPLIANCE 5.00
PLAN CHECK
,
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 1QD000.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE
r70
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
1 hereby affirm that there is a construction lending agency for
the pT,forinanoe of the work for which this permit is issued (Sec.
3097, Civ.0 J.
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATI NG UN IT (OV ER 100,000 B.T.U.) 9.50
ELECTRIC
Lender's Name
Lender's Address
VENTILATION FAN (SINGLE) 4.00
PLUMBING
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
BOILER-CO&V(3 H.P. or 100000 B.T.U.) 6.00
,
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives ofthis city to enter upon the
above-mentioned property fort Peet ion purp s.
(W ce to ve, i e uify and kee armless the City of
Cup, ino on hald le judgments, S and expenses which
ma in an ac a ainst Id CIn consequence of the
gr lingo t per
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
/ YO
Signatl'A can /Con o Date.
ure o
OFFICE COPY