7047APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION•
APPLICATION & PERMIT
BUILDING —ELECTRICAL— PLUMBING —MECHANICAL
PERMIT NUMBER
7047
BUILDING n
ADDRESS i- vv.
rvAMf. OWNEn,s
1 t ry q T�'7• L �,j
af.H'ryk j+ } •'e t
C1 1141 ,ELEC'TRIC PERMIT , aF',EE;:
PLAN CHECK VALIDATION
NAMERgcroR'S
OUTLETS -SWITCHES - RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
LIC. No.
CNTRACONTRACTOR roR's
ADDRESS
APPLIANCES -RESIDENTIAL 4.00
PANELS 5.00
- PHONE
DATE OF APPLICATION
ARCHITECT
ENGINEER
LIC. ND.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENG'
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
ZIP
V J
Ar$
DN[55
ADDRESS
MOTORS SEE FEE SCH.
•
lf ps(
/ V OJ•�
SERVICE CHANGE - 10.00
LICENSED CONTRACTORS DECLARATION
I hereby allium that I am licensed muter provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Cl Crede, and my licence is in full force and effect.
'ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
❑ ❑ ❑ ❑
Dat.ClassC.ENumher
Date Con[raclor
-
ION
from
y'BUILDING�PERMIT
MISC. — REFER TO ORD
rm that IBUILDER t
I hereby al'Orm that I am exempt from the Qmtractor's License
the
Low for the following reason. (Sec 7031.5, Businessand Professions
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, lir repair any structure, prior to its issuance, also
rCQlllres the applicant for such permit to file a signed Statement that
he Is licensed pu sualll to the provisions Of the Contractor's License
Law (Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
Business and Professions Code) or that he is exempt lhemfr.m anA
the basis for the alleged exemption. Any violation of Section 7031.$
by any applicant for a permit subjects the applicnnuoo civil penalty
of nor more than five hundred dollars (4500).):
Ta INFORM— ION
- —
PERMIT ISSUANCE 6.00
ELEC. CONTR, LIC. N0. ELEC. a'
TOTAL
VALUATION $/FT.
• 14 '
PERMIT TO
L V
s
DT,V,. :• 1 - -PLUMBING PERMIT FEEp+a
STORIES
p
dl Upertlno
,TYPE CONSTR.
ALTER -DRAIN 0
ALigt
TER--WATER IEA.)q.2.2
El 1, as owner of the property, or my employees with wages as
m
their sole Copeosatioti, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES: UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
-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 4.00
GAS - EA. SYSTEM -11NC.40UTLETS
property who holds or improves thereon, and who does such ..,it
himself or Ihrough [Disown employees, provided that such improve-
omntsarenot intended oroffered for sale. If, however, the building
SO. FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner -
builder will have the hlinten of proving that he did not build .,,in
GAS - EA. SYSTEM - OVEfl 4 (EA.) 7,QQ
BUILDING USE
prove for purpose of Sade.).
❑ I, as owner of the properly, am exclusively contracting with
RES IND CON FB Omer
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
licensed contractors to construct the project(See. 7044, Business
and Professions Code: The Contractor's License Law does riot apply
to au owner of property who builds Ur improves thereon, and who
ASSESSORS PARCEL NO.
contracts for such Projects with a contract.,(,) licensed pursuant to
the Contractor's License Law.
❑ 1 am exempt under Sec. , B.&P.C. for uus
11.1.11
SEWER-SANITARV-STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
Owner Dat _ _
_AI
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER
WATER TREATING EQUIP: 4.00
WORKERS'CO DECLARATION
RATION
-
I hereby affirm that I have a certificate rife Ent to elf -insure,
ZONING
ENG. SITE NO.
or a certificate of Workers' Compenvlion Insurance, ora certified
copy thereof(Sec. 3800, Lid, C,).
Policy No. Company
❑ Certified copy is hereby furnished,
Applicant ❑ Certified copy is filed with the city inspection division.
MISC. - REFER TO ORD.
FIRE SPRINK
V [:] ONE C3
ENERGY T 2
v [-]N[]
CERTIFICA1 E OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
.FLOODZONE
A.L.UC.
COMPENSATION INSURANCE
I'I'his section need not be completed if the permit is for one
PLG. CONTR. LIC. NO.
PLG.
TOTAL Q
V ❑ N[]
V ❑ N�
hundred dollar, IS I Win, less.)
1 certify that m the performance of tirew ork for which this per-
mu Is issued, I shall not employ any person in any manner so as m
DTV' MECHANICAL PERMIT -' FEE:
1 ?'F7,EEiSUMvRBv
becomesubject to the Workers' Compensation Laws of Calil'urnia.
OR ADD TO MECH. - 4.001BUILDING
Date�ApplicantALTER
NOflCE TO APPLICANT: II', after making This Certificate of Ex-
APPLIANCE 4.00
AIR HANDLING UNIT (TO 1Q000GF.M.) 3-00
PLAN CHECK
FEE
emption, you should become subject to the Workers'Compensation
provisions of the Labor Code, you must forthwith comply with
such Provisions or this permit shall he deemed ervoked.
AIR HANDLING UNIT (OVER 10000C.F.M.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hemby affirm first the. is a coo ftoction lending.gency let
EXHAUST HOOD (WITH DUCT) 2.00 .
the performance of do ..,it for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT ITO 100,000 B.T.U.) 4.00
Ltaumr's Name
Lender's Address
HEATING UNIT (OV ER 100,000 B.T.U.)7.50
ELECTRIC
I certify that l have read this application and stale that the above
information is cored. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and.
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER -COMP (3 H.P. Of 100,000 B.T.U.) 4.00
hereby authorim repmsenlatives of this city to enter upon the
above-mentioned property for inspection purposes.
BOILER-COMP(Ove1100,000BTUISEE FEESCH.
MECHANICAL
(We) agree to save, indemnify and keep harmless the City of
Cu rhino against liabilities, judgments, costs and expenses which
y in any way accrue against Said City in consequence of the
mnl' g of this pe 1 I �.
MISC. - - REFER TO ORD.
PERMIT ISSUANCE 3.00
CONST. TAX
MECH. CONT. LIC. NO. MECH.
TOTAL
-
^TQTAL a
y '1 " V '
Ignalure of Applicant/ [DECnfnr ale
OFFICE COPY