8191 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
8DLILDING APPLICATION & PERMIT
7C ADDRESS OT Q Pal
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL p 4,
4W% d444 U
- PLAN CHECK VALIDATION
"AME QTY. ELECTRIC PERMIT FEE
AfA 11 644) PHONE
am RACTo UTLETS-SWITCHES-RECEP 10.00(1.00
NAME
LIC.NO.
LIGHTING FIXTURES 10.00/1.00
A APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARc ITf PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
\, OR
F ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.08 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
Ars
ADDRESSDDRFSS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 q
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
G v U I hereby affirm that I am licensed under provisions of Chapter 9 ' ISSUANCE DATE
y "' (commencing with Section 7000)of Division 3 of the Business and
Q vAi BLDG. ELECT. PLG. MECH.
F y. Pro Cessions Code.m my license is in ful"ATION et ❑ ❑ ❑ ❑
o z m Qct' License Cle. Lia N'untb )(
� Dale��3�y� Qntl recto
BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUB-DEiR DECINFORMATION
OpD M1SC.- REFER TO ORD
w ; se I hereby affirm that 1 am exempt from the Contractor i License VALUATION SIFT.
F ac o a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE - 10.00
Code:Any city or county which requires a permit to construct,alter,
¢ ¢ 4 2 improve,denmlish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /(? // ��O
u w a u requires the applicant for such permit to file a signed statement that TOTAL ,0 PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
z r
Law(Chapter 9(commencing with Section 7000)of Division 3 of the f'/z(/G.��igxy,C �GarEL
i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ I- o the basis for the alleged exemption.Any violation oCSection 7031.5 STORIES TVP CONSTR.
n ; T by any applicant for a permit subjects the applicant to a civil Penalty ALTER-DRAIN IEA) 5 , / �[
of not more than five hundred dollars(S500).): . .00 � f'V// �.
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sal,(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
n
Code:The Contractor's License Law does not apply to uowner of
property who builds or Improves thereon,and who lines such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself through his own employees,provided leve such improve-
mems are r ot through his o n employees,
ees,pr lL ed thathowever the buildimprove-
.cuts e- GAS-EA.SYSTEM-1 INC.4OUTLETS 6.00
or improvement is sold within one year of completion,ore owner- GAS-EASYSTEM-OVER 4 IEA) 200 BULLoeNG-USE
builder will have the burden of pr . . .
Flowing that he did not build or ire- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSOSPARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to au owner o1property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with v emltrach m)licensed pursuant to SEWER-SANITAR V-STORM EA.200it/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ 1amexempt tinder See. ,B.&P.C.lor this WATER HEATERW/VENT 6.00 6U(r( U
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificuec of consent to sell-insure' ZONINGOra certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO,
i copy thereof(Sec.3800,Lab.C.).n
Policy No. Company 1"
Q ❑ CeHiN ropy is hereby[urpizhcd. FIRE SPRINK ENERGY T-24
z Z ❑ CerHB J 'op hie wit the city ins Ettore division.
O Applicaut MISC.- REFER TO ORD. Y � NF] Y0 N�
CC y PERMIT ISSUANCE 10.00 FLoo020NE A.L.u.C.
LU CER ICATCQ N SA . 'LION NS PROM WORKERS'
W fed let A ON Iced if the
PLG.CONTR, LIC.NO. PLG. V D NE] YE] N❑
D Z (This doll rs need not be colnplcted if the permit ix for one TOTAL
hundmJ dolens IS 100)or less.)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
O w ri msa
become subject to the WorkeCopention Laws of California.
a Datc ApplicantALTER OR ADD TO MECH. 5.00 BUILDING ,(
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject In the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions n1' the Labor Code, you nnut forthwith comply with FEE
U such provisions or Hits permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 6.00 SEISMIC FEE j 7
1 hereby IT,. that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
are performance of the work for which this permit is issued(Sea MICROFILM
HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's NamAddy HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
l certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information iscorrect. I agree to comply with all city unA county PLUMBING
ordinanceS and state laws relating to building conseructinn, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property foi inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cup$ ino against liabilities,judgments, costs and expenses which CONST.TAX
my i any way a frlTe against said City in consequence of the PERMIT ISSUANCE 10.00 G2
g antif g of this Per lit. • MECH.CONT. LIC.NO. MECH.
- TOTAL TOTALC�/fA kr „2a F7
Si turco Ap is /Contract r )a
INSPECTOR COPY