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8968APPLICANT TO FIkT,=F"NFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER BUILDING ADDRESS a 6�I Ge u BUILDING - ELECTRICAL- PLUMBING - MECHANICAL OWNER'S "AM=-^^' _ HONE 16' OTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION NAME ADT Rs OUTLETS-SWITCHES-RECEP 10.00/1.00 ML LiC NO. b a- , DATE OF APPLICATION LIGHTING FIXTURES 10.00/1.00 nooeEss 7OR's ' N` Cf PHON -37.22 APPLIANCES- RESIDENTIAL 4.00 PANELS IO.00 OORRcmTEOT - ENGINEER uc. No. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ARCH. OR ENG, ADDR> SPECIAL CIRCUIT S.00 PERMIT VALIDATION TEMP. METER OR POLE INS. 20.00,,,lo ZIP APPucANrs MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 ;Ysq ARVI-Ax l LICENSED CONTRACTORS DECLARAT ON TEMP. POLE 2.00 �` I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code d nmy license is in full ' License Cas s • Lic. Numberr Date Contractor �:ys_�gC�w OWNERiBUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, atter, ISSUANCE DATE BLDG. ELECT. PLG. MECH. ❑ ❑ ❑ /�. doper ino BUILDING PERMIT INFORMATION MISC. - RELFLEA TO ORD VALUATION $/FT. PERMIT ISSUANCE 1000 . ELEC. CONTR. - LIC. NO. ELEC. TOTAL 3 QTY. PLUMBING PERMIT FEE 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 to the provisions of the Contractor's License Law (Chapter 9(commencingwith Section 7000) of Division 3 oflhe Business and Professions Code) or that he is exempt therefrom and PER "IT=O ��� r%,ld TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 703 1.5STORIES by any applicant fora permit subjects the applicant loacivil penalty of not more than flue hundred dollars (5500).7: ALTER-DRAIN-WATER(EA.) 5.00 ❑ I, as owner of the Property, or my employees with wages as their sole compensation, will do the work, and the structure is not - BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA,COND. 5.00 intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of FIXTURES - PER TRAP 5.00 GAS-EA.SVSTEM-11NC.40UTLETS 6.00 50. FT, FLOOR AREA TOTAL ACREAGE property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- ments am 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 he did not build or im- for prove 1, aso nee of sale.). ❑ L as owner of the properly, exclusively contracting with GAS - EASYSTEM -OVER 4 (EA) 200 . .. BUILDING USE RES IND CON PB Other INDUSTRIAL WASTE INTER. 30.00 he the project (Sec. 7044, Easiness licensed contractors : TheC Contractor's does not apply and Professions Code: The Conbuilds 's License s thereon, to owner of property who builds improves thereon, and who LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 LAWN SPRINKLERS -OVER 5 (EA.) 1.00 ASSESSORS FARCE L NO. tr contracts for such projects with a contructarts) licensed pursuant to tr the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO, PARCEL NO. ❑ lam exempt under Sec. ,BAP.C. for this reason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have -a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. I copy thereof (Sec. 3800, Lab.C.). /1�. -Policy No. Company �7 T ❑ Certified copy is hereby famished. ❑ Certified copy is filed with the city inspection division. Applicant FIRE SPR INK V N ❑ ❑� ENERGY T-24 V N ❑ MISC.- REFER TO ORD. CERTIFICATE OI' EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONEA. L.U.C. COMPENSATION INSURANCE (This section need not be completed if the permit is for one PLC. CONTE LIC. NO. PLG. TOTAL Y ❑ N Y N hundred dollars IS 100) or less.) -I certify that in the performance of the work for which this.per. mit is issued, I shall not employ any person in any manner so as to QTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of CaBf..D ia. Date Applicant ALTER OR ADD TO MECH. 5.00 NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption, you should become subject to the Workers' Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FEE AIR HANDLING UNIT (TO 10=C.F.M.) 4.00 AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for - EXHAUST HOOD (WITH DUCT) 5.00 the performance of the work for. which this permit is issued (Sec. 3097, CiE.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Add., HEATING UNIT 100,000 B.T.U.)9.50 ELECTRIC I C3o --- I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and PLUMBING BOILER-COMP(3 H.P. Dr 100,000 B.T.U.) 6.00 BOILER -COMP IOvar 100,000 BTUI SEE FEE $CH. MECHANICAL hereby authorize representatives At this city to enter upon the above-mentioned property for inspection purpous. (We) agree to save, indemnify and keep harmless the City -Of MISC. - REFER TO ORD. CupeIt' o ainsl liabilities, jud mems, casts and expenses which may I way accrue a 'n sail City in consequence of the gmnli o his permit N -YO "�Ii CONST. TAX PERMIT ISSUANCE 10.00 MECH. CONT. LIQ NO. - I I MECH. TOTAL TOTAL I' Si atur of licanl/Cont actor OFFICE COPY