12597 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
SG APPLICATION & PERMIT
ADDRESS 0! BUILDING — ELECTRICAL—PLUMBING—MECHANICAL 12597
P
OWNERS PLAN CHECK VALIDATION
NAM QTY. ELECTRIC PERMIT FEE
PHONSCAU
c cT s OUTLETS-SWITCHES-RECEP 10.00/1.00
d
LI N LIGHTING FIXTURES 10.00/1.00
.G rRACTOR's91
APPLIANCES-ADD s RESIDENTIAL 4.00
J PHGN dJ%JPANELS 70.00 DATE OF APPLICATION
C IT T PANELS (OVER 200 AMP) 20.0U PLAN CHECK FEE P.C.NO.
OR
ENGINEER
- uc.rvo. SIGNS TRANS. 3.00
ADDRESS
APPLICANTS
ENG. SPECIAL CIRCUIT 5.00 RWTyAdDATION
ZIP EMP.METER OR POLE INS. 20.00 JULW II CJS
ADDRESS MOTORS SEE FEE SCH. J — 9 gs^ag
ADDRESS I y�'
SERVICE CHANGE 20,00 r' f"x11
Cirri LICENSED CONTRACTORS DECLARATION ��OF CUPtN/11yu
< L,U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
a < (commencing with Section 7000)of Division 3 of the Business and SLOG. ELECT. PLG. MECH.
r D i Professions Code nd icense is in full for a i ❑ ❑ ❑
z D in Lice is Class "� Lic.IN
9 m w Date Contractor
Q y 3 J
W. BUILDING PERMIT
¢ ¢w OWNEftBUILD1iR DfiCLARATION INFORMATION
WO¢ 1- 1 hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
3 U. VA WATION S/FT.
F LL o J Law for the following reason.(Sec.703I.S.Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city Or county which requo"a permit to construct,alter, ELEC.CONTR. LIC.NO.
Q S, ¢ p Improve,demolish,or repair any structure,prior to Its Issuance,also ELEC.
¢ wDLL requires the applicant for such Permit to file a signed statement that TOTAL PERMIT TO
$ he is licensed pursuant to the provisions of the Contractor's License
� ZY Law(Chapter9(commencing with Section 7000).(Division 3ofthe
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
Etc
¢ H the basis for the alleged exemption.Any violation of Section malty STORIES TYPE CONSTR.
by any applicant fora hundred
subjects S5000.licunlloucivilpenalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred Dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
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 SO.FT.FLOOR AREA TOTAL ACREAGE
himselfor through his own employees,provided that such improve-
mentsamnot intended orofficmd forsale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
O I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 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(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SAIR E .2 / 0. 0
the Contractor's License Law. .& C�n TRACT NO. PARCEL NO.
Ift
❑ lam exempt under Sec.—,BP.C.for this WATER HEA N• LIM
reason
Owner Date
WATER SVST i 5 ALC.DATE ACL,FILE NO,
WORK ERS'COMPF.NSATION DECLARATION WATER TREA G EQUIP. .O 2
I hereby affirm that I have 3 certificate of consent to self-insure, T
or a certificate of Workers'Cope 'lion 1/Lance,or a C fried
DA1 ZONING ENG.SITE NO.
Coope
copy thee- f ec.3800r LaM1.C.1. �fJ.
Policy N Company
O ❑�•rtil doe ishereb furni5 ed FIRE SPRINK ENERGY T 24
Z Z ,[S Cert' m �o y is fit w'tli he city Peet division.
O AppOc;yi MISC. REFER TO Y❑ N❑ Y ❑ No
CC W CERTIFICATE OF EXEMPTION P OM RK E S PERMIT ISSUANCE FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO.
CL
d O (This section need not be mmpletcd if the peruit is her one TO �� Y[DN❑ Y❑ N❑
=) Z hundred dollars IS 100)or less.)
L) O 1 certify that in the performance of the work for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f mil is issued,I shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Laws of California.
UJIIa.
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Fx-
F ? emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 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 ITO 1O=QF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction tending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 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 BOILER-COMP I3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws minting to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP IOver 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.
jSm,'�,RA
ertliabilitidgments, costs and expenses which CONST.TAX
in accrueinst said City in conseque ce of the PERMIT ISSUANCE 10.00CONTC.N0. MECH.
TOTALTOTAicant/ on[mctor ate
OFFICE COPY