6273 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 6273
ADDRESS
BUILDING — ELECTRICAL—PLUMBING—MECHANICAL
OWNERSh� ` -- PLAN CHECK'VALIDATION
NAME pL.� C �•�`/�y� yJ 7� QTY. ELECTRIC PERMIT FEE
� E �J Jw 1 1 VHONE (p
CONTRACTORRS'S
/ NAME„LJ ,n,_nte�d' UT LE -SWITCHES-RECEP 5.00/1.00
l� I LIc.No. 8Z` LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
g;Q ✓T, ,RdHONE ✓ " 'PANELS 5.00 DATE OF APPLICATION
ARCHOECT SIGNS 600 PLANCHECK FEE P.C.NO.
OR .
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
AlDuo sEND. SPECIAL.CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDHESS
SERVICE CHANGE 10.00
w o z LICENSED CONIBACTORS DECLARATION + ru U` D—31:e
c I herehy affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H GEvinumencing with Section 7000)of Division 3 of the Business and L G. ELECT. PLG. MECH.
F yrs' Professions Codyy,and Ir(Ey�license n in full fore;ayQ Ree. ❑ - ❑ ❑
z
0. License CI,Iss_L=3Y_Lie.Number�' 1 L
]p
m o a OWNIi R-BUILDER DECLARATION RGOSif� 1 ILDING PERMIT
a u, INFORMATION
is 3: REFER TO ORD
w g 0< I hereby al tiro that 1 um exempt from the Contractor's License MISC.— _ L v S/FT
I- LL o¢ Law for the following ntaon,thee.requires
Business and Professions PERMIT ISSUANCE 6.00 ,a V
Vi Code:Any city or county which reyuires a permit m is issuance,
alter„ /✓b
p -improve,demolish,or repair any structure,prior to its issuance,alio ELEC.CONTR. LIC.rv0' ELEC.
—0¢ W(mics the applicant lilt such permit to file a signed statement that TOTAL "tZt:JdJIMIT TO
x m he is licensed pursuant to the provisions of the Contractor's License
A. F z i [.aw(Chapter 9(commencing with Section 7000)of Division 3 of the D
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢.F o the basis Ior the alleged exemption.Any violation of Section 7031.5 STO ES - T P CONSTR.
a ;m by not
that fora permit dollars the for civil penalty ALTER-DRAIN -WATER (EA.) 4.00 TR. (s ✓t=
of nut more than fort hundred donuts the applicant
.): r�
❑ I,:as owner of (tic property,or my employees with wages as ..BACK FLOW PROTECT. DEVICE 2.00 , OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is nil
intended or inhered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF;AREA,COND. 4.00
Code:The Contractor's License Law docs not apply to an owner in -
_ property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
t himself or through his own employees,provided that such improve-
{� 'meats are not intended or offered for sale.If,however,the building ( GAS-EA.SYSTEM-1 INC.4 OUTLETS 4-00
or improvement is sold within one year of completion,the owner- GAS J EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have thc.burden of proving that he did not build or int-
prove for purpose ofsalc.). INDUSTRIAL WASTE INTER. 20.00 RS IND C PB Omer
❑ L u owner of Om property.am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to con.Mrbct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code rhe Contractors License Law does not apply
to an owner of properly who builds or improves thereon:and who LAWN SPRINKLERS OVER 5(EA.) 1.00 -
contracts for such projects with a contractors)licensed pursuant 10
the Contractors Litems Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 4.00
reaou
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
'WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a cert ilicate of Workers Compensation Insurance,ora certified
a lyth r I'(S �3�1P0'�O,�
policy No ABO3j 'u4111�f
O C. •.d opy i,aherchy cd _ FIRE SPRINK ENERGY T 24
Z z0 o C RI'is 1 py is fl d it c y ns division. MISC -.:.REFER TO ORD. ❑ ❑ Q ❑
A It 'l l V N V N
+ ~-Z2 PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.UC,
— it H](AII Or Ii XEMPTION FROM WORKERS*-. . -
W > COMIINSATION INSURANCE it PLG:CONTR. , LIC.NO. PLG. Y❑ N❑ Y ❑ NEICL O- 1'l1n, welkin need not be completed if the pemnil is for one TOTAL
:) z hundred dolho;(S 100)or less)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I— mit is issued,i shall not employ any person in any manner so as to
O beconrc subject to the Workers Compensation Laws of California.
o- Dare Applicant ALTER OR ADD TO MECH. 4.00 BUILDING it
} to NOl'1 CE TO A111)1.[CA NT: In.after.making this Certificate of Iix-
? enmtion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
par visions of the Labor Code. you must forthwith comply with FEE
U Inchprosi cm,it this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONST RUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 101MC.F.M.) 5.00 SEISMIC FEE Of
I hereby'affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perlonnanee of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender;Name
ender' 's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
L
I certify that l have rad this application and state that the above VENTILATION FAN (SINGLE) 3.00
- -
::iforamoon is correct.1 agree to comply with allity and county PLUMBING
d and :rt I s rel Yng to buildingconstruction,_. and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
her by arthorme representatives of this city to enter upon the BOI LER-COMP(Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for Inspection purposes.
(We) agree to save, indemnify and keep harmless the City of - MISC.- REFER TO ORD.
Cupeado against liabilities,judgments, costs and expenses which CONST.TAX
may in any.way accrue against said City in conse9ucnce of the PERMIT ISSUANCE 3,00
granting of this permit MEDIA,CONT. LIC.NO. MECH.
.or Iaur�W j�l8�fi'� TOTAL TOTAL
Signature of A ppIicmR/Cont Octor Dater
OFFICE COPY,-.