10853APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
q O r
I `�
BUILDING
ADDRESS 11796 PINE BNOOK LANE
OWNER'S Ydl)
NAME J 7V71 LAOS_
MUKO 69 TT PRONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
LD
IP � 0 '
JUN 16 1992
DATE OF APPLICATION
CONTRACTORS
rOUTLETS
NAME
Culligan LIC No
-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
GNrRAcrDR's
iDjjl
jFs§ Ru 5 S o l l Ave PRONE _
APPLIANCES- RESIDENTIAL 400
.
PANELS 10.00
OORR//CR//ITE}CT
ENGINEER
uc. ND.
PANELS (OVER 200 AMPI 20.00
'LTN No.
SIGNS TRANS. 3.00
ARC" OF ENG
SPECIAL CIRCUIT S.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
G`�^
!�
AE
ADDRDDRESSSS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
1775 Russell Avg SC CA.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9
ISSUANCE GATE
(commencing with Section 7000) of Division 3 of the Business and
Professions Code and m license is in full fore � and eff I.
License Class_ Lic. Number
BLDG. ELECT.
❑ ❑
PLG. MECH.
❑
Date L- IL- ContractorCoi/ri/, &A
BUILDING PERMIT
INFORMATION
OWNFR-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License
Law for the following reason. (See. 7031.5, Business and Professions
Code: Any city or county which requiresa permit to construct, alt,
MISC.— REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION 7
$/FT.
ELEC. CONTE. LIC. N0.
ELEC.
TOTAL
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
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
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Anyviolation of Scelion703L5
by any applicant for a permit subjects the applicant to a Civil penalty
of not more than five hundred dollars (8500)):
ALTER -DRAIN -WATER (EA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sale compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4,00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
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-
mentsarenotintendedorofferedforsale. If, however, the building
F IXTUR ES - PER TRAP 5.00
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner
builder will have the burden of proving that h e did not build or im-
prove for purpose of sale.).INDUSTRIAL
❑ I, as owner of the property, am exclusively contracting with
.
GAS - EASYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Omar
❑ ❑ ❑ ❑ ❑
.
WASTE INTER. 3000
licensed contractors to construct the project (See. 7044, Business
unit Professions Code: File Contractor's License Law dues not apply,
to an owner of property who builds or improves thercon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a conlractods) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft 10.00
/
TRACT NO.
PARCEL NO.
❑ lam exempt under Sea ,B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKE RS'COMPF-NSATION DECLARATON
1 hereby affirm that 1 have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof e. 3 00, Lab.CJ. (1 y
Policy No. ompany Cr-,J4Pr.4
'
FIRE SPRINK
v ❑ N❑
ENERGY L24
v ❑ No
Cl Certified copy lrhereby furnished.
❑ Certified copy's filed with the city inspection division.
APPlic:mt
MISC.- REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE .+I69O
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
(This section need not be completed if the Permit is for one
PLG. CONTE, LIC. NO.
PEG'
TOTA
V N
[D❑
Y N
❑ ❑
hundred dollars IS 100) or less.)
1 certify that in the performance of the work for which ill's per-
mit is issued, 1 shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Worker' Compensation Laws of California.
Date Applicant
NOTICI7 TO APPLICANT: If, after making this Certificate of Ex.
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
emptOn, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=11F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LANDING 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.
3097, Civ.C.).
MICROFILM
H EATING UN IT (TO 100,000 B.T.U.) 8.00
Lender's Name
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lender's Address
1 certify that 1 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
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMP(3 H.P. Dr 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,0000TU)SEE FEESCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mevribRed property for inspection purposes.
MISC. - REFER TO ORD.
We) gree save, indemnify and keep harmless the City of
tino agains liabilities, judgments, costs and expenses which
a way accrue against said City in nse,p rice of (hc
CONST. TAX
PERMIT ISSUANCE 10.00
n' 'S mit.
%i
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
Contractor a e
\� "I I OFFICE COPY