4344 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NO PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 4344 3 4 A
a DREss
Q � , �„ BU `?
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ILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NaM /J (/.111 ,� ^1/1A/
QTV. ELECTRIC PERMIT FEE
VVI enONE .
CONTRACTORS
),_Ny�4 E L/ OUTLETS-SWITCHES-RECEP 5.00/1.00
Flt' 00 11,6) LIC.No, -7 /I LIGHTING FIXTURES 5.00/1.00 -
CONTRACTOWS r �- C
ADDRESS / ^ `ML APPLIANCES-RESIDENTIAL 4.00
IC 4-e-6L.✓ CJ0 1 NE '29.5- PANELS 5.00 DATE OF APPLICATION
OR
RCHITECT SIGNS 6.00
PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,NO, SIGNS TRANS. 3.00
ADDRESS ENR., SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS.- 15.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
w¢z
Foo LICENSED CONTRACTORS DECLARATION _
a u 1 hereby affirm that I am licensed under provisionsof Chapter 9
2 w ISSUANCE DATE
m ¢ y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F o z Professions Co an4 license is in full for fee. ❑ ❑ ❑ ❑
zo Oz v'Ai o tLicense Clas Lia Number !!
_Contractor _
¢ ¢wa OWNER-BUILDER DECLARATION
BUILDING PERMIT
a o¢ " INFORMATION
X g'. n I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD �U
u Law for the(.flowing reason.(Sec.7031
O¢ .5,Business anJ I'r.fessions ISSUANCE 8.00
P/k�U 1� $/FT.
FN0�l Code:Any city.,county which requiresa permit to construct,alter, PERMIT /�7
raQ ¢ 0 improve,demolish,Or repair any structure,prior to Its Issuance,also ELEC.CONTR. LIC.NO.
ELEC.
G¢ requires the applicant for such permit m file a signed statement that TOTALIT TO
u w m u he is licensed pursuant to the provisions of the Contractors LicenseZ 114
F z a Law(Chapler 9(commencing with Section 7000)of Division 3 ofilic 4
R�2o0i
R mirs
4 O Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ r� the basis for the alleged exemption.Any violation of Section TYPE CONSTR.
a by any applicant fora pert subjects the applicant tocivil penallymalty
of not more than five hundred dollarslS5001.1: ALTER-DRAIN& VENT-WATER (EA.) 4.00 X�/dAl
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE - 2,00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not N�tJ
,
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOORROOFAR EA,CON D. 4.00
Code:The Contractor's License Law does not apply to an owner of , ,
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP. 4.00 so.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve,
Bents are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
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. GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
prove for purpose o titleJ' INDUSTRIAL WASTE INTER, Y0.00 O IND e❑oN O Other
❑ d as..net of the property,am exclusively. 7044, Eng with
licensed contractors l0 construct the project La 7044,of apply LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The who
Contractor's License Law does not apply
to l owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for is projects with a contructnrts)licenser]punu:uv to
the Contractor's License under
Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,RSP.C.lir this
reason WATER HEATER W/VENT 4.00
'
Date Owner WATER SYSTEM 4.00 ACC.DATF ACD.FILE NO.
WORK ERS'coMPliNsn'1'ION IniCLAeniu)N WATER TREATING EQUIP. 4.00
I hereby affirm thus I have a"i-ni ate of cnnscnt to self-insure,
Dr a certificate of Worke,s'Compmtsalion Insunmcu,or a ecruhitd ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lah,C.). -
Policy No. Company
C ❑ Certified copy isherchy furnished. FIRE$PRINK ENERGY h24
Z Z ❑ Certified copy is filed with the oily inspection division,
O Applicant MISC.- REFER TO ORD, v ❑ - N❑ v ❑ N❑ -
CL y CERTIFICATE OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLooD ZONE a.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTH. tJC.NO. PLG.
C O (This section need nut be connpleled if the permit is for one TOTAL V❑ N❑ V ❑ N❑
Z no n Bred dollars IS 100)or less.)
U Q 1 certify that in the performance of the work for which this per- QTY- MECHANICAL PERMIT FEE FEE SUMMARY
LL mit is issued, 1 shall not employ any person in any manner so as to
} be<ope ject}p�he Workers'�(Smpe�ntie�n f,uv2Y of Cul'urniq
U y
Dat '�2 Applicant/[,ft AZT.-F !NeL ALTER OR ADD TO MECH. 4.00 BUILDING
rn NOTICE TO APPLICANT: If,after making this Certificate of I:x-
? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
U
provisions of the Labor Code, you must forthwith connply with FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE J�
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(Sre. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county g01LER-COMP13 H.P.or 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
above-mentioned property for inspection purpoS. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) Ole to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupert against liabilities,judgments, costs and expenses which CONST.TAX
ma any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
in ofthisper l' MECH.CONT. LIC.NO. MECH. �J
_�� TOTAL TOTAL
natureof Applicant/Contract., Uare O L
OFFICE COPY