09710 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
DNsAPPLICATION & PERMITADRE: o �SuN
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 09710
OWNER'S PLAN CHECK VALIDATION
7C NAME CITY. ELECTRIC PERMIT FEE
�CkA-pt-�101 PHONE
• CONTRACTORS
�( NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
rA 4.wUC.N//�2-01 LIGHTING FIXTURES 10.00/1.00
x roNTRACTons APPLIANCES-RESIDENTIAL 4.00
� AooREss ^
• L (1 �. VHONQ D Q PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR (((��� ///��r a�r�/ PANELS (OVER 200 AMP) 20.00
ENGINEER 1 JC✓d O`✓frl 1.
r EkitgL I� - uC.No. SIGNS TRANS. 3.00
nooa'ESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00
ADORESS
AMOTORS SEE FEE SCH.
ORE55
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP. POLE 30,00 /
< U u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
O1 (commencing with Section 7000)of Division 3 of the Business and
ti D A BLDG. ELECT. PLG. MECH.
r r I'mfcssmns Cn�ujS� urnu4�rrppyy beers is in fillNumber I'orcc and cffuct. ❑ ❑ ❑
xx
o i tjq iJi,ense Class__Li,.Number
Dula W" Contractor Llnr ,..
" a OWNER-BUILDER Orr.L R-I ' Ic'rtF BUILDING PERMIT
a 3 p U INFORMATION
X ; y 1 hereby uflirnt that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
H w o to Law for the following reason.(Sec.7031.5,Businessamf Professions PERMIT ISSUANCE 10 00 VALUATION $/FT.
Code:Any city or county which requires a permit to construct.alter,
2 2¢ improve,demolish,or repair any structure.prior 10 its issuance,also ELEC.CONTR. /' LIC.NO. ELEC..
a wLL requires the applicant for such permit to file a signed statement that •� TOTAL PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License
F z s- Law.(Chapter 9(commencing with Section 7000)of Division 3 ofthe /yam
4 O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE / /
¢ H O the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ; m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars f 5500).):
❑ 1,as owner of the property,or my emldoyees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the sl ruclure is not
intended or offered lot sale (See 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONO. 5.00
Cod,:*1'he Contractor's License Law does out apply to an owner of
property who builds or Improves thereon,and who(toes such work FIXTURES-PER TRAP 5.00 SO,FT,FLOOR AREA TOTAL ACREAGE
. himself or through his own employees,provided Omt such implove-
atentsare not intended oroffered for safe.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 200
builder will have the burden of proving that h - . - . .
e did nut build or int- BUILDING USE
prove for purpose o(salr.. INDUSTRIAL WASTE INTER3000 RES IND CON PB Other
. .
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ El ❑
licensed contractors to construct the project(See. 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 properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a cmVractorls)licensed pursuant to
the Contractor's License Law. -1 SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sea.-,B&P.C,for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACCDATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
' I hereby affirm that I have a certificate of consent n.self-insure.
of u certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy thea fS '.3 00,Lab C..
rmEey N impart IuELNd
O Certified copy is hereby'furnished, fIRE SPO INK ENERGYT 2C
Z
2 e Certified opy rs tiled .th the city inspection division.
O Applicants �� }( MISC.- REFER TO ORD, v N v N
cc rn A �� 9 PERMIT ISSUANCE 10.00 ❑ ❑ ❑ ❑
LU CIiR'I'IPICAT OMPE EXEMPTI ON PROM WORKF;RS' FLOOD ZONE A.LO.C.
CL
COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v� N� Y � N�
d O (('his uctimt need'not be completed if the permit is for one TOTAL
Z hundred dollars(5100)or less. -
C) O 1 certify that in the performance of the work for which this per TV. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- nt it is issued,1 shall not employ any person in any manner so as to 7E
O become subject to the Workers Compensation Laws of California. d
0- Date Applicant I BUILDING
>- N NO'fl Cli 10 APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F Z cmption,you should become subject to the Workeri Compensation APPLIANCE ' 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
GJ such provisions or this permit shall be deemed revoked. - AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOC.EM.) 6.00 SEISMIC FEE
v Ir-here4L affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 `7 _�
the performance of the work for which this permit is issued ISec. MICROFILM
3097,Ctv.C.. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T,U,)8,50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above V ENTILATION,FAN (SINGLE) 4.00
information is correct 1 agree fl comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordiainfor ave,tio send stale laws relating to comply
with roily an ion, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100AOOBTU)SEE FEESCH. MECHANICAL ��-
ubove-ntnnlioned property for inspection purposes.
(Wu'')kk�gory to save, indemnify and keep hmniless the City of MISC.- REFER TO ORD.
Cupertind uyaire t liabilities,judgments, costs and expenses which CONST.TAX
may in fig' uy accrue ag t said City in consequence of the PERMIT ISSUANCE 10.00
�. grand tis permit MECH.CONT. LIC.NO. MECH.
,// TOTAL C93 TOTAL
Ngm4a A licant Contractor Da e
INSPECTOR COPY
t