4479•X
•
•
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN
,(Y n
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
UILDING- ELECTRICAL- PLUMBING -MECHANICAL
T NUMBER
4479
"LOINc
AODRESS / /•
Vl
OWNER'S-
.. .'', '1
OTY. ELECTRIC_ PE RMIT,- -FEE'
PLAN CHECK VALIDATION
-
GATE APPLICATION
CONTRACTORs _
NAM
.a. .sec. No.
UTLETS-SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
co RACTOR s
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
ARCRITEC
OR
ENGINEER
A /241 LIC. NO.
SIGNS 6,00
PLAN CHECK P.C. NO.
K
SIGNS TRANS. 3.00
ARCH. oR ENG.
AODRESS
ZIP
SPECIALCIRCUIT 5,00
R1111 'ISATION
PJ[[..ii]]LLLLVV
QCT
`s l{y of CoDedino
EMP. METER OR POLE INS. 15.OU
APPLICANT'S
ADOREs�,`S"/^ I
Cl
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATIONrs
o j,
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
ProCode. ''cosiisNi full fore f t
se
ISSUANCE GATE
BLDG. ELECT. I PLG. MECH.
❑
enfessions
Licse lass Number
_d
Date Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
n,(Sec. 7031.5. Bunessand Professions
Law for the following rcawsi
Code: Any city or county which requiresa permit to construct, alter,
Improve, demolish, or repair any structure, prior to Its Issuance. OISU
requires the applicant for such permit to file a signed statement that
he is licensed pursuant w the provisions of the Contractors Licenser
9(commencing with Section 7000) ofDivision 3 of the
and Professions Code) or that he is exempt therefrom and
basis for the alleged exemption. Any violation ofSection 7031.5.'
byanyapplicantforapermitsubjectstheapplicanttoocivilpenaltyALTER-DRAIN&VENT-WATER(EA.)4.00If ofnot more than five hundred dollars(S5001.):❑ 1, as owner of the property, or my employees with wages asBACK
their sole compensation, will do the work, and the structure is notintended or offered for sale (Sec. 7044. Business and ProfessionsDRAINS-FLOOR,
,
-BUILD❑ ING PERMIT Jr,
': f' INF.ORMATION
MISC. - REFER TO ORD
VALUATION S/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. N0.Pam
ELEC.
TOTAL
PERMIT TO
RMITLaw(Chapter
F7Business
. • -:
�.I '+'
.. 'PLUMBING PERMIT- 'FEE',TORIES
�' '- + - - -
TYPE eONSTR.the
FLOW PROTECT. DEVICE 2.00gCc.
GR U
RES. UNITS
ROOF, AREA, COND. 4.00Code:
The Contractor's License Law does not apply to an owner ofproperty who builds or improves thereon, and who does such workFIXTURES
himself or through his own employees. provided that such improve-GAS-EA.SYSTEM-11NC.4OUTLETS
meets arc not intended or offered for sale. If, however, the buildingor
FT aooR AREA
TAL ACREAGE
- PER TRAP 4.00so.
4.00
- EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
IND PB Omer
❑
improvement is sold within one year of completion, the owner -GAS
builder will have the burden of proving that he did not build or in, -RES
prove for purpose of sell.).
❑ 1, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, BusinessNKLERS
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and whoNKLERS
contracts for such projects with a contractors) licensed pursuant toITARY-STORM
the Contractor's License Law.
❑ l am exempt under Sec.., 9 &P C. for thisATER
L WASTE INTER. 20.00
- 1 INC 5 V.B. 5.00
ASSESSO PARCEL NO.
- OVER 5 (EA.) 1.00
FSEWER-SANITARY-STORMEA. 200ft/8.00
TRACT NO.
PARCEL NO.
W/VENT 4.00
reasonDate Owner
STEM 4.00
ACC. DATE
ACC. FILE NO.
WORK ERS'COMPENSATION DECLARAT ON
1 hereyyg�g�1 !� tt/�e'�� Y aJ�(/� sell -insure.
or rISF(c 5f NottefFs eoRrPCns tiAr(I(Isi r�iice. or a ce rti(icd
EATING EQUIP. 4.00
ZONING
ENO. SITE NO.
sore '(Sec. 3ROO. Lab.y l "(
Policy No. Company J. -K
❑ Certified copy is hereby furnished.
❑ Certifie Py is fled with thV)ity inspection division.
FIRE Sir
YE] N[D
ENERGY T-00
vE] NE]
MISC.- REFER TO ORD.
Applicant
PERMIT ISSUANCE 6.00
FLaOD 20rvE
A.L.U.C.
CER IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action need not be completed if the permit is for one
hundred dollars IS 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any perwn in any manner so as to
became subject to the WorkersCompensation Laws of California.
DaleApplicant
NOTE TO APPLICANT: If, after making this Certificate of Bx
IC
emptiun, you should become Subject to the Workers' Compensatiun
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCYAIR
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec
Y IN
y N �
PLG. CONTR, LIC. NO.
PLG.
OTAL
° '' °
OTY. MECHANICAL PERMIT FEE '
_ -
- , ,<nE,
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10,OODC.F.M.) 3.00
HANDLING UNIT (OVER lOfMC.F.M.) 5.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
ELECTRIC
3097, Civ.C.).
Lender's Name
HEATING UNIT (OVER 100,000 B.T.U.17.50
Lender', Address
I certify that lhave read this 'utionand stat hal the above
infnrmatio 'orrect, l acre• oc mPly witha city and only
oNinan s and tate laws latin• to huildil camtrucY n, and
hereb owhon, reprcu nWs t this ci to aster Pon the
-menhoric propert for ins ection P poses. a) agree t save ndcmny and ep harm s the City of
C Perrino agai St list, hies, j gine casts expenses which
VENTILATION FAN (SINGLE) 3.00
G
BOILER- COMPO H.P. or 100,000 B.T.U.) 4.00
CALabo
KHTAN
BOILER -COMP (Over 100.000 BTU) SEE FEE SCH.
MISC. - REFER TO ORD.
AX
PERMIT ISSUANCE 3.0r
ay III any0
fan oft d a I t see og' est mi CUnse °I
MECH. CONT. LIC. NO.
MECH.
TDTAL.TOTAL'.
I��.S3
`
Ig /Col ate
OFFICE COPY