5650APPLICANT TO FILL IN INFORMATION WITHIN RED LINES _ USE BALL POINT PEN ONLY
' BUILDING PROJECT. IDENTIFICATION
-. APPLICATION &'PERMIT
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BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
5650
BGILDI`G - .. - .
ADDREss ` ' I
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EL C TRIC P MI EE
PI AN CHECK VALIDATION
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" DATE OF APPLICATION
CONTR/aCTORS -
N,AME�/
L960 a/,�,,' "•'C'
67LeZ4. LIC. No.TJ.�'2(
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OUTLETS - SWITCHES -RECEP 5.00/1.00 cJ
LIGHTING FIXTURES 5.00/1.00
EONTRACTOR's - :
p�R/��s�s�
PHONEjMj 13 • I Z
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT
.OR
ENGINEER -
_ - ,LIC. No.
SIGNS - 6.00
PLAN CHECK FEE , P.C. NO. "
,
:, SIGNS TRANS.'. - 3.00
ARCH. OR ENG.. .. -
ADDHESS ,, -
-° SPECIAL CIRCUIT '5.00
PERMIT VALIDATION
.. EMP. METER OR POLE INS. 15.00.
zIF
APPLICA
APPLICANT'S
MOTORS S
Z`C Xk -SEE FEE:SCH.
SERVICE CHANGE •' 10.00
LICENSED CON" TRACTORS DECLARATION
K
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` I hereby affirm that I am licensed under provisions of Chapter 9
(commemmg �with Section ]000) of Division 3 of the Business and
Professions Cade, an my license S m full torr Ed e f c v.
e='
License Class Lie m Nua
.Date 7•/ + Contreclo"
OWNER -BUILDER DECLARATION -
I hereby affirm that 1 am exempt from'6e Contractor's License
Law for the following reason. (See, 703 1.5, Business and Professions
. Code: Any city or county'which requires a permillocons(rucl, alter,•"""'�'
improve, demolish, or repair any structure, prior to its issuance, also '
requires the applicant for such permit to file a signed statement that
he is licensed pursuant the provisions of the ContrRclor: Licehse;
Law (Chapter 9(commencingwith Section 4000) of Dmaion3ofthe'
Business and Professions Code) or (hal he is exempt tlmrefrom and
the basis for the alleged exemption Any violation
byanyapplicantfor a permit subjects the applicant toacivil'penalty.
of not mom'than five hundred dollars (1500).): ^
ISSUANCE GATE
BLDG. ELECT. PLG. MECH.
❑ ❑ ❑
i
1 ''
a .
BUILDING PER
INFORMATION JIIIIIIIIIIIIIIIIIIII
I a. MISC. .REFER TO ORD P°
;'-PERMIT ISSUANCE 6.00 (�
VALUATION $/FT.
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J,EC. CONT LIC. NO. G- ELEC.
GGrr�lff Z O /� TOTAL,
J L YJ
�` "a,';p, '0trvrvea' "(s s. '-w °1t'
OTY. PLUMBING�•N, 6RMIT FEE
Ax xf%
PERMIT TO
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£LCC /' '
STORIES
TYPE CONSTR.
ALTER -DRAIN -WATER (EA.) 4.00
❑ Las owner of the property, or my employees with wages as'
their sole compensation, will do the work, and,st
the ructure isnot
ggCK'F LOW PROTECT. DEVICE 2.00
OCC. GROUP
RES.UNITS
RES,UNITS
DRAINS -FLOOR, ROOF,'AREA,COND. 4.00
or offered for sale .(Sec. 7044, Business and Professions
Code: The on License Law does not apply to an owner of
FIXTURES-, PER TRAP, 4.00
GAS-EA.SVSTEM-11NC.40UTLETS 4.00
BD. FT. FLOOR AREA
,
TOTAL ACREAGE
property who builds or improvesthereon, and who does such work
himself through his own employees, provided that such improve-.
arents are not intended or offered for sale.' If, however, the building'
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that lie did not build or im-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
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GAS EA. OVER 4 (EA) 1,00
BUILDING USE
HES IND . * CON PB' Omer
❑ ❑ O, ❑' - LJ'_
INDUSTRIAL WASTE INTER. 20.00
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licensed contractors to construct the project (Sec: 7044, Business
and Professions Code:.The Contractor's License Law does not apply
to an ..net of propertylwho builds or improves thereon, and who
' contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law. 'y,,.'
❑ late exempt under Sec: - ,e.&P.C. for this
reason
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRIN KLERS'OV OVER 5 (EA.) 1.00
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ASSESSORS PARCEL NO.
''SEWER -SANITARY -STORM EA. 200ft/8.00.
TRACT No. '. PARCELING.
WATER HEATER W/VENT 4,00
Owner Date
WATER SYSTEM,, '4.00
ACC. DATE - 'ACC. FILE NO.
'. WATER TREATING EQUIP. " 4.00
WORKF.RS'C6;/MapI 7�1 ECLARATION
I hereby affirm t t1 M1e a certificate of consent to self -insure,
or a certifica ers' Compensation Insurance, ora certified
copy Cher fee. R00, Lab.CJ. hH.n1IN/J..
I ZONING - ENG. SITE NO.
Policy Na� otop n �IJLV ay
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MISC.-. REFER TO ORD.
FIRE SPRINK, ENERGY T-24
�' O
V N V N
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Certired.egi to Dished. the
CerliO dOath h the city inspection division
A plcant
'•, CERTIFICATE OF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE " '
fl'his section need not bc'completed if the permit is for one
-. PERMIT ISSUANCE' - 6.00
FLOOD ZONE A.LU.C.
Y ❑ NO•„ Y rye
PLG. CONTE. LIC. NO.
t " - - - - -
PLG.
TOTAL
hundred dollars($ 100) or less.)- '.
certify that'.in the performance of the work for which this per-
init is issued, I too I.nmt employ any person in any manner so as to
become subject to [he Workers' Conmensation Laws of California.
- •s w- REE
OTLY MECHAN CAL PERMIT FEE
A, * •. a
FEE SUMMARY
A0
OR ADD TO MECH. 4.0 .0
Date ApplicantLTER
BUILDING..
NOTICE TO'APPLICANT: If, after making this Ccaifica(e,of Ex-
APPLIANCE 4.00
PLAN CHECK
FEE 'I
eniption; you should become subject to the Workers;Compcuxmiou
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 1QOODC.F.M.) 3.00
AIR HANDLING UNIT(OVER IQOOOC.F.M.) 5.00 <' .'
SEISMIC FEE'
CONSTRUCTION LENDING AGENCY • -
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097,Civ.C.). _
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EXHAUST HOOD (WITH DUCT) 2.00
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'MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) '4.00
Lender's Name
Lender's Address - - - -
N
HEATING UNIT (OVER 100,000 B.T.U.P.50
ELECTRIC
'VENTILATION FAN,(SINGLE) -'3.00
-PLUMBING
1 certify that I have read this application and statelthat the above
,
information is correct. I agree to comply with all city and county.
ordinances and state laws relating to building Construction, and'
he,authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
BOILER- COMP (3.H.P.oY100;000 B.T.U.) 4.00
"'BOILER-COMP'IOveF.t00,000 BTU) SEE FEE SCR .
?'MISC.
MECHANICAL
(We) agree to save, indemnify and keep harmless the City of
• ` REFER TO ORD.
opertain t li bililies, judgments; costs and expenses which•.
mw a erne against said City in consequence f the
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PERMIT. ISSUANCE 3,00ai
CONST. TAX
MECH-CONT - LIC NO MECH.,•
TOTAL
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TiOi�T"�ALg
m 4 R Np�pmva d'
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ppbcant/Contractor 'Date
+ OFFICE COPY, - -