14815 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT[FICATION - PERMITNUMBER
ADDRESS _ �j APPLICATION & PERMIT O
ZJ �jQC—S LUGE� 122 BUILDING—ELECTRICAL—PLUMBING—MECHANICAL L• O 5
OWNER'S
NAME C�(V/LL.r-(. FF PLAN CHECK VALIDATIONppp
LtJ(N EstOV aVtio�✓/O ft, QTY. ELECTRIC PERMIT FEE
R �O�a 70 yc�
NAMERACTORs UTLETS-SWITCHES-RECEP 10.00/1.00 / -LIC.NO LIGHTING FIXTURES 10100/1,00 .
ADDRESSR
TOS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION'
ARCHITECT G5N5��� O�foYa'3 PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
EENGINEER Q'/�(TE1i'/S t,3 I,Z
UC.NO. 3 SIGNS TRANS. 3.00
ARCH.OR ENG
ADDRESS R YO M�avo� ' •�5 SPECT METER
5.00 PERMIT VALIDATION
g�3U� EMP.METER OR POLE INS. 20.00 _ -
ADDRESsTs MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
o i
F0
O LICENSED CONTRACTORS DECLARATION
a v I hereby affirm thin I am licensed under provisions Of Chapter 9
te 4 e' (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE '
H ]Z Professions Code,and my license is in fell force and effect. - BLDG. ELECT. PLG. MECH.
a 0 w W License Class Lic.Number
w r Date Contractor
4 m E
M OWNIi R-BUILDIiR DECLARATION BUILDING PERMIT
0> INFORMATION
.X ;o. w I hereby affirm that I am exempt from the Contractor' License MISC.— REFER TO ORD
F LL O j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE VALUATION $/FT.
Code VAR city or c
oo
nty which req vires a permi[to<ons[rucLulteq 10.00
ut Q improve,demolish,Or re an Slru¢t"re, nor to its issuance,also ELEC.CONTR. LIC.N0.
a ¢ O Pair y p' ELEC.
m u req an Pc the applicant far Such permit t0 file a signed statem¢nt that TOTAL PERMIT TO
n w he a licensed pursuant to the provisions ol'the Commctor's License -
Hz> Law(Chapter9(commcrem"witssSeclmn7000jofUivision3ofthe sl-DD�7ioNp�1 ladE
4 4 O Business and
Professions Code)or that he is exempt Therefrom and OTY. PLUMBING PERMIT FEE
X H m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A. 3�, by any applicant fora permit subjects the applicam toacivil penalty ALTER-DRAIN (EA.) 5.00
of not more than five hundred dollars($500).1 -
❑ Las owner of the property,a my employees with wages us BACK F LOW PROTECT.DEVICE 4,00 DCC.GROUP RES,uwTs ,ti,-
Their sole compensation,will du the work,and the structure is not
I
ntended 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 docs such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4'OUTLETS- 6.00
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 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
prRES IND CON PB Omer 1
❑ 1,as owner of the property,am exclusively contracting with 0'
licensed contractors to construct the object(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 thereot and who LAWN SPRINKLERS•OVER 5(EA.) 1.00
contracts for such projects with it contractors)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ Tum exempt lender Sec. ,B.&P.C.for this
mason WATER HEATER W/VENT . 6.00
Owner Date WATER SYSTEM - 5,00 ACC.DATE ACE FILE NO.
WORKS RS'COMPENSAT10N DECLARATION WATER TREATING EQUIP. 5.00
I 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.
copy thereaf(Sec.3800,Lab.C,).
Policy No. Company
Q ElCertified copy is hereby lurnisheJ. - FIRESPRINK ENERGY T-24 r
Z Z ❑ Certified copy is filed with the city inspection division.
F O Applicant MISC.- REFER TO ORD. v 0 N v No
CCN CERIIFICA'IE OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 O (This section need not be completed if the permit is for one TOTAL Y N❑ Y❑ N
Z hundred dollars IS 100)or less.)
U O
- mit I certify that in the performance of the work bar which this per- CITY MECHANICAL PERMIT ''FEE FEE SUMMARY
U_ 1is issued,I shall not employ any person In any nmnner so as to
O W become subject to the Workeri Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ CO NOTICE: TO APPLICANT: If,alter,making,this Certificate of Ex-
FZ emption,you should becomesuhjeefto the Workers'Compensation APPLIANCE 500 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with .
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10Oo011FEEF.M.) 4.00
CONS"TRUCION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is aconstruction lending agency I'.. EXHAUST HOOD(WITH DUCT) 5.00 -
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lemhu'x Name
Lender's Address HEATING UNIT(OVER 100,000B.T.U.)9.50ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 1
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 6.00
hereby entiorim representativesofthis city to enter upon the BOILER-COMP(Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for tativ inspection this
purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
uperlino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 10,00
ranting of this permit, MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature of Appbcant/Contractor Date
OFFICE COPY