6935 PLICANT TO FILL IN INFORMATION WITHIN,RED LINES — USE EIALL.POINTPEN ONLY
BUILDING PROJECT I DENTI F CATION PERMIT NUMBER
UI LDING - APPLICATION'& PERMIT ,a
aooREss .• .-6 ll J C
BUILDING—ELECTRICAL:-PLUMBING—MECHANICAL JJJ
OWN R'S ,�. PLAN CHECK VALIDATION
"" QTY, LECTRIIC P RMIT FEE
s p $$�
/ PHONE 'w :. v
co oRS - UTLETS-SWITCHES-RECEP '5.00/1100 -
• [t I, _ ® G uc.No. LIGHTINFIXTURES - 5.00/1.00 -
-TnR SST S QQ - APPLIANCES-RESIDENTIAL .400 _ w�
PJOPRONE <D/ PANELS S OO DATE OF APPLICATION
aRCHfT C - - SIGNS _ y 5 DO •j, - PLAN CHECK FEE;. P.C.NO.
OR• , C'
ENGINEER
!( I.M.NO. . SIGNSTRANS.,.:, .300
.ARCH.ORENG - - PERMIT VALIDATION
.AGOREss ' SPECIALCIRCUIT C 500
' {
ZIP TEMP.METER OR POLE INS. 15.00
.aPPuca"r5 MOTORS 'SEE FEE SCH'.
A A
p^ C SERVICE CHANGE '10.00 YY'
o ¢i I ..
-,C2 LICENSED CONTRACTORS DECLARATION ��/'��
¢lu F"
u i hereb ffrm rico[I am licensed ov Bions of Cha lei 9
U Y a I n under pr i p ,
a,z ,a ISSUANCE DATE
�
(commencing with Section 7000 of Division 3 of the Business end
( g )
m¢ w µ. - BLDG. ELECT. PLG. MECH.-
• r o Professions Co end my license is in full for J eH
iC V LD cfic sCyt Lia Num !J ❑
O z r w: Date %C _ Contractor'
OWNER-BUILDER DECLA�A�I N /y BUILLD. IN,�Li�PyERM T
tw ;u, A ':1 hereby affirm that I am exempt from thGContractor's License MISC.—, - REFER TO ORD EN - TyION
u C¢ Law far the following reason.(Sec.7031.5;Business and Professions VALVA $/FT.
Code:Any city orcounl which requires permit to ConstrrmLalter, PERMIT ISSUANCE 6.00'
• ¢ Q
improve,demolish,nt for such
any structure,prior 10 its issuance,also ELEC.CONTE. LIC.NO. ELEC." ��'J(_V �4 4 1
S'O¢
requires the applicant for such permit to lite a signed statement that TOTAL •- -PERM
0'
IT TO
6•w m he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 of the 'Ivvi,'° 21Yh, t&:d,'
E,i o Bdsness and Professions Code)or Thal he is exempt therefrom and QTY. PLUBINQ-PEflM1✓sT, - FEE I
¢'H'm. ,the basis for the alleged exemption.Any violation of Section 7031.5 p%q {A x.`'v a... ,gai` ''N;' -a 1n E' 'r•` STORIES TYPE CONSTR.
a.3 � by any applicant for a permit subjects the applicant to's civil penalty gLTER-DRAIN VENT-WATER (EA.) 400 v
of not more than five hundred dollars($500).):
th -
-❑� G I,as owner of the property,or my employees with wages as - BACK FLOW.PROTECT.DEVICE 2.00' , OCGROUP RES.UNITS
en sole compensation,will do the work,and the structure is not
intended or offered for to(Sec. 7014, Business and Professions' DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code;The Contractor's License Law does not apply to an owner of
.property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employers,provided that such improve-
ments arenot intended oroffered for Sale.If,however,the building GAS-,EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is Sold.within one year of completion,the owner- GAS-EA.SYSTEM—OVER 4(EA.) 1-DD BUILDING USE
buildenwill have the burden of proving that he did not build or im- RES 'IND. CON PB Omar
prove for purpose of sale L-, - "- INDUSTRIAL WASTE INTER. , 20.00
❑. 1,as owner of the properly,am exclusively contracting with, ❑ ❑ ❑ ❑ ❑-
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. - 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5.MA-) 1.00 ,
contracts for such projects with a contractor(s)licensed pursuant t
'
[lie Contractor's License Law. - - SEWER-SANITARYSTORM EA.20011/8.00 TRACT NO. PARCELNO.
'I am exempt under Seca ,IV&P.C.for this WATER HEATER'W/VENT 4.00
reason
Owner' Dale,' WATER SYSTEM 4,DO - ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a cerliEcate of consent self-in re, ,
or a certificate of Workers'Comp _[ion 1' e, quer tied ZONING ENG.SITE NO.
copy thereof(See.3800,L.ab.C). - -
policy No. Company "
A.
O'. ❑ Cetilied opy s hereby f rnXd.
z Z ❑ Certir ", n is toed with the city inspection di inion. FIRE SPRINK ENERGY T-24
APPhcanl�Tf / /' MISC.- REFER TO ORD. v.❑ 'N❑ p ,v ❑ N❑
~ m F ` E � PT WORKERS' PERMIT ISSUANCE
LU > CEiuIF CCOMPENSAT ON INSURA CE 1 PLG.CONTE. LIC.NO.' PLG:6.00
� FLOOD ZONE A.L.0 C.
C- O (This section need not be completed if the,permit is for one TOTAL Y❑ .N[] Y ❑ No
0 Z - hundred dollars($100)or less) " -r - t a
U.O I certify that in the performance of(he work for which this per. QTY MECHANICAL•PEflMIT FEE FE SUMMARY
., LL F mit is'issued,1 shall not employ any person m any manner so as to '°$ w
U become subject to the Workers'Compensation Laws of Coliforms.
w '- Date Applicant ,x - - BUILDING•- d(J
4,} y NOTICE TO APPLICAN I':.If,after making this Certificate of Ex-
emption,you should become subject to the Workers'Compensation APPLIANCE - - 4.00 "PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE'
U' such provisions or this.permit shall be deemed-revoked.' AIR HANDLING UNIT(TO 1Q000GF.M:) .3,00 '
s CONSTRUCTION LENDING AGENCY' AIR HANDLING UNIT(OVER 10,00)C.EM) 5.00 SEISMIC FEE SO
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. .MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U:)' 4:00
Lender's Name HEATI NG UN IT ER 100,000 B.T.U.)7.50 '
Lender's Address- ELECTRIC
•I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct Pagrec to comply with all city and county , BOILER-COMP(3 H.P:Of 100,000 B.T.U.) 4.00 PLUMBING .
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to'enter upon the BOILER-COMP (b.,IW000RTU)SEEFEESCH. MECHANICAL•
above-mentioned property for inspection purposes. -
(We a me to save„indemnify and keep harmless the'City of MISC.- REFER TO ORD.
' Cuper .against I' bi' es,judgments, costs and expenses which" PERMIT ISSUANCE - 3.00 CONST,TAX
may e w c against,said City Inc nseq ence of the -
gra f rq MECH.CONT., - LIC.NO. MECH V s ug ra' a
TOTAL •, M• re.Pf l�j ,
TOTAL C1'
au o plicant)Con[rac(or ere - k`•4-w 'j4vA ,Log
OFFICE COPY - �s '