18873 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT f' 873
ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL ') 8 o
1\5 \.
OWNER'S PLAN CHECK VALIDATION
NAME
^ 3(01 V• ELECTRIC PERMIT FEE app®
CONTRACTORS
NAM OUTLETS-SWITCHES-RECEP 10.00/1.00
I.C.NO JDO5 LIGHTING FIXTURES 10.00/1.00
ADORE sTDes PPLIANCES-RESIDENTIAL 4.00 t
T 11 ST / PANELS '10.00 D%VGpf Cunedin0-.
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
uc.No. SIGNS TRANS. 3.00
noo'Ess sr+c. SPECIAL CIRCUIT 5.00 I
^PERMIT VAL ATI
�� .
ZIP EMP.METER OR POLE INS. 20.00 ,
noo ass Ts MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
' 00 LICENSED CONTRACTORS DECLARATION ��� -
it. -I hereby affirm that I am licensed under provisions of Chapter 9
Z w ISSUANCE DATE
y a N (commencing with Section 7000)of Division 3 of the Bminesa and BLDG. ELECT. PLG. MECH.
H m z Professions Code))nd my license is in IiJI fur f t. ❑ ❑ ❑
o z w o License ClS�$�_Lic.Number -
q S99
N F Uate T-4�• Contractor_ �,�
It a w ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
w0 n I hereby affirm that I am exempt tram the Contractor's License MISC.- REFER TO ORD INFORMATION
r w o j Law for the following reason.(Sec.703I.S.Business and Professions PERMIT ISSUANCE 10.00 VALUATION SIFT.
f �> E Code:Any city orcounty which requires a permit to construct alter,
K st G improve,demolish,or repair any shucture,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
G an m
requires the applicant for such permit to file a signed statement that
n w l TOTAL s License PERMIT TO
ri
Law 9(commencing with Section 7000)of Division 3 ofthe
Q
E i G Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
r F the basis for the alleged exemption.Any violation of Section 7031.5 S RIES TYPE CONSTR.
n 3 aO by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars($500).): ALTER-DRAIN& V,ENT-WATER (EA.) 5.00 .
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.CROUP RES.UNITS
sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply m an owns,of
property who builds or improves omrcon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.ll',however,the building GAS-EA.SVSTEM-11NC.4OUTLETS 6.00
or innprovement is sold within one year tit completion, the owner-
builder will have the harder n of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
Prove for purpose ofsa]c.). RES IND CON PB Other
❑ 1,as owner of the Property',am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
license) contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code The Contractors License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractoda)licenud pursuant to
the Contr:mtor's License Law, SEWER-SANITARY-STORM EA:200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec._,B,&p.C.for this
reason WATER HEATER W/VENT
OwnerDarr WATER SYSTEM .00
ACG DATE ACC.FILE N0.
WORK Fai S'coMPHn'sAT10N DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to Bell-insure,
or u certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thercof(Sec.3800,Lab.CJ-
Policy No. Company
O ❑ Certified copy is hereby furnished.
z Z ❑ Certified copy is filed with the city inspection division. FIRE SPRINK ENERGY T24
Applicant MISC.- REFER TO ORD. v � N� v � NE]
~ O PERMIT ISSUANCE
jr CE k'1'I FICA l ATIOTION FROM WORKIiRS' •OO FLOOD ZONE A.L.U.C.
W � COh1I'IiNSAT10N INSURANCE, PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed it the permit is for oneTOTAL J�,W Y❑ N Yo NE]
Z) Z hundred dolhus(S 100)r Icss.)
El
U O 1 certify that in the performance of life work for which this Per- GTy MECHANICAL PERMIT FEE FEE SUMMARY
LL - mit is issued,I shall not employ any person in any manner so as to
0 Ltbeconm subject to the Workers'Compensation Laws of California.
a Datc AFIllcunt BUILDING
} to NOTICE '1 O APPLICANT: It after nn akin,this Ccrtil'icate of Ex- ALTER OR ADD TO MECH. 5.00
F 2 emption:you should become subject to life Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisiu., of the tabor Code, you must forthwith comply with FEE
U such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CRiati 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF M.) 6.00 SEISMIC FEE
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. MICROFILM
3097.r's Na). HEATING UNIT ITU 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify 11311love,,ad t his application and State that the above VENTILATION FAN (SINGLE) 4.00
.y information is correct. I agree to comply with all city and county .PLUMBING
ordinances and state laws relating to building construction, and BOILER-CO MPOH.P•or100,000B.T.U.) 6.00 /J
hereby authorize representatives of this city to enter upon the
abovo-mentioned property for inspection purposes. 801 LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree tole
cove. indemnify and keep harmless the City of MISC.- REFER TO ORD.
upertino againliabilities•judgments, costs and expenses which CONST.TAX
ay in any waccrue against said City in consequence of the PERMIT ISSUANCE 10.00
,an
I Rus rmit. /{ MECH.CONT. LIC.NO. MECH.
T 1�`�• TOTAL TOTAL
t eofAIT ucint/Cont, r Date t"�.Ioo
OFFICE COPY