7235 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
ADDRE
I DING -ELECTRICAL-PLUMBING-MECHANICAL 7235
owNEe'S - PLAN CHECK VALIDATION
NAME 7•�7'
�JU TY. ELECTRIC PERMIT FEE
I PNONE JU
NAME OR UTLETS-SWITCHES-RECEP 5.00/1.00
LIc. LIGHTING FIXTURES 5.00/1.00
NTRA[ OR'S - e
PPLIANCES-RESIDENTIAL 4.00
_ PNOry PANELSS.00 DATE OF APPLICATION
OF NITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDDRESS ENa SPECIAL CIRCUIT 6,00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 15.00 01
�J
APPLICANTS -
ESS MOTORS SEE FEE SCH. !i
SERVICE CHANGE 10.00
w
00 LICENSED CONTRACTORS DECLARATION '
u w 1 hereby affirm IhCI I am licensed under provisions of Chapter 9 ISSUANCE DATE
• w a w (commencing with Section 7000)of Division 3 f the Business and BLDG. ELECT. P G. MECH.
o H w z Professions Cod•9n kense is in full f ❑ ❑ t ❑
Z,0 w- License Class Lic.Num
w w
Date contract
Q x
c ¢sr<a-' OWNERBIILUFR DECLARATION
BUILDING PERMIT
o INFORMATIONw
3.LL 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
uOa Law for the following reason.(Sec.7031.5,Business and Professions VALUATION S/FT.
-w PERMIT ISSUANCE 6.00
E y> 4 Code: e,y chy or county whiny strrequcture,p roil to construct. also after. >
K Q O improve,demolish,or repair any structure,prior[o its issuance,also ELEC.CONTR. LIC.NO. TL IT. '
O u requires the applicant for such permit to file a signed statement that TOTAL - pgtdlT TO
E:
he is licensed pursuant to the provisions of the Contractor's License ,(.•///_,
riQ Law(Chapter 9(commencingwilh Section 7000)of Division 3 oflhe
4 D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
M r.m the hasis for the alleged exemption.Any violation ol'Seclam 703 LS
TORIES PE CONSTR.
a 3 .- by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500)):
O I,as owner of the properly,or my employees with wages as 6ACK FLOW PROTECT.DEVICE 2.00 OCG GROUP
their sole compensation,will do the work,and the structure is not RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions
Code: ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
,. propertywho buildsor improves thereon,and whodoes such work FIXTURES-PER TRAP - 4.00 60.FT.FLOOR AREA TOTAL ACREAGE
himself or throughhhis own employeesprovided who
such improve
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or Purpose INDUSTRIAL WASTE INTER. 20.00 lO a❑ON P❑e DOe
` ❑ I,as owner of the property,am exclusively contracting with
licensed contsactors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 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 it contruclods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.20008.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec..,B&P.C.for this
reason WATER HEATER W/VENT 4.00
OwnerDate WATER SYSTEM 4.00 ACC.DATE ACC FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsen Yt If-i rte, - ZONING ENG.SITE N0.
ora certificate of Workers'Compensation sl n ,ora fieri
copy the ate of Workers'
yom,
Policy
U' ❑ Certified copy is here furnished. ` 1 FIRE SPRINK ENERGY TZ4
Z Z ❑ Cerfificd copy Is 11.4•• city insp lion division.
FO Applicant!P•L. � MISC.- REFER TO ORD. y � NE] Y❑ N�
Cr CERTIFICATE Ob'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A,L.U.C.
(L C1 (This section need COMPENSATION
beTcompletedRif thepermitis for one TOTAL
CONTR. LIC.NO. TOTAL Da Y N� Y[] N�
LLj D
� Z hundreddollars($10OorlessJ
U O 1 certify that in me performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL mil is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
a Date ApplicantBUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of lix- ALTER OR ADD TO MECH. 4.00
~ Z emplion,you should become subject to the Workeri Compensation APPLIANCE
provisions of the labor Code, you most forthwith comply with 4.00 PLAN CHECK
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10MC.F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C_F.FA) 5.00 SEISMIC FEE
I hereby affirm that here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 ,
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U. 4.00
Lender's Name HEATING UNIT(OVER 100,000 S.T.U.)7.50
Lender's Address ELECTRIC
I certify that 1 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 PLUMBING
ordinances and slate laws relating to building construction, and BOILER COAT 13 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives for ins inspection
city to enter upon etre BOILER-COMP(Over 1(0,000 BTUI SEE FEE SCH. MECHANICAL
nerve-mentioned properly force of-thi purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Caped' against babililies,judgments,costs and expenses which pERM1T ISSUANCE 300 CONST.TAX
CC
' By in
accrue against said Cily i consequence of the
gm�ng fly 1. ECH.CONT. UC.NO. MECH.
/} TOTAL TOTAL
Si' ren A mane I clor Date U
OFFICE COPY