8485APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION
& PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
8485
BUILDINGAPPLICATION
ADDRESS RESS
lJ
OWNER'S
NAME
- II//
(qqn/%N VI BRDNE
Qom. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTORS [
Q yl(. ua No.
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS DOHESTRACroR's
APPLIANCES - RESIDENTIAL 4.00
PANELS ' 1Q00
PRONE
DATE OF APPLICATION
RCRITE r
O
OR
NGINEER
LIC. NO.
PANELS (OVER 200 AMP) 20,06
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS LNG.
SPECIAL CIRCUIT 5,06
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
noDROESS s
MOTORS SEE FEE SpH.
SERVICE CHANGE 20.00
61
LICENSED CON I PACT ORS )ECLARATION
TEMP. POLE 30.00
---
1 hereby.]firm that I am licnnsed under provisions of Chapter
(cunnrmncing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full t.4 ad c fact.
Licen�se Class Lic. Number
ISSUANCE DATE
BLDG. ELECT. PLG: MECH.
❑ ❑ ❑
Datc'Y'
BUILDING PERMIT
INFORMATION
7_ YJContractor
T ��O •WNER-BUILDER DECLARATION
I hereby attire that I am exempt from the Contractor's License
Lew for the following reason. lSec. 703 I.S, Business and Professions
Code: Any city or county which requires permit to construct, alter,
MISC.- REFER TO ORD
PERMIT ISSUANCE 10�
VALUATION
SIFT.
ELEC. CONTR. LIC. N0. ELEC. �0
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
Law (Chapter 9 (commencing will Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
QTY. PLUMBING PERMIT FEE
['�C�
C
tha basis for the alleged exemption. Any violation of Scetlpn 7031.5
STORIES
TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more Hiatt five hundred dollars (5500).):
ALTER -DRAIN -WATER (EA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
. .
BACK FLOW PROTECTDEVICE 400
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
'
FIXTURES - PER TRAP 5.00
50, FT. FLOOR AREA
,
TOTAL ACREAGE
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
GAS - EA. SYSTEM- 1 INC.4 OUTLETS 6.00
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-
prow for purpose ofsole.).
❑ I, as owner of the property, ant exclusively contracting With
- . -..
GAS EASYSTEM OVER 4 (EA) 200
BUILDING USE
REs IND CDN Pe Omer'
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
licensed contractors to construct the project (Sec. 7044. Business
and Professions Code: The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon. and who
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts lin such projects with a contractors) licensed pursuant to
the Contractor's License Law.
SEWER -SAN EA. 200tt/10.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Svc,-, B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Uate
/' WATER SYSTEM 5.00
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKERS'COMPENSATION DECLARATION
I hereby al firm that I have a certificate of conxnt to self -insure.
or a certificate of Workers' Compensation Insurance, or a certified
-
ZONING
ENG. SITE NO,
_. MISC. - REFER TO ORD.
copy thereof(Sec. 3800, Lab.0 I '
Policy No. Company
Certil'i� ) b Is q/� op, n y u
H colt Yd(�le with the '['ny�7fRlf`•[titfH`i�((fiA.
Applica" . �Gd--
FIRE SPRINK
Y ❑ N ❑
ENERGY T 4
y
Y ❑ N❑
CERTIFICATE OF EXEMP'T'ION PROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A. L. u. c.
COMPENSATION INSURANCE
('this section need not be completed if the permit is for one
Y ❑ N ❑
Y ❑ N ❑
PLG. CONTR. LIC. NO.
PLG.
TOTAL
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 person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOT ICI: TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10MC.F.M.) 4.00
PLAN CHECK
FEE
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you runt forthwith comply with
such provisions or this permit shall he scented revoked.
AIR HANDLING UNIT(OVER I0)000C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
lire perm. anceof tpe work for which this permit is issued (Sec.
3097, Gv.C.L , /
Aww
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lcndcr's Address
HEATING UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
JC_
VENTILATION FAN (SINGLE) 4.00
I certify that 1 have read thisapplication and state that the above
information is correct.'I agree to comply with all city and county
ordinances and slate laws relating In building construction, and
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCM.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cup- I. o against liabilities, judgunents, costs and expenses which
mo in ny Way a true against said City in consequence of the_
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.001CONST.
TAX
gr' LLil hi it,MECN.
CONT. LIC. NO.
MECN.
�s
TOTAL
TOTAL
{na are (Applicant/Contractor Date
INSPECTOR COPY