17576 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING . APPLICATION.& PERMIT
AODR0 OBUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1 57 v
OWNER'S PLAN CHECK VALIDATION
NAME
DI �ur90- dtc 5►31`S QTY. ELECTRIC PERMIT FEE -
1 l rAl S 9
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
bGaAt ezeNC'N.D. 0'S9
LIc.N.D. LIGHTING FIXTURES- 10.00/1.00
cDNTRACTO 's PPLIANCES-RESIDENTIAL 4,00 -
S J J r eVU10 o r^�7 PANELS 10.00 DATE OF APPLICATION
ARCHITE PLAN CHECK FEE
MP,C,NO.
F� PANELS (OVER 200 AMP) 20.
uld 1 �/ S�C3,�'A�� TRANS. .00
AR CH.OR ENG. PERMIT VALIDATION
ADDRIf - r C SPECIALCIR fi-..--. 5,00
UQ J /4A/,I�c�4CC' •• zlfy�1' EMP.METER OR POLE INS. - 20.00 -
APPLICANT - MOTORS. SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
Woo LICENSED CONTRACTORS DECLARATION
Q U U I herebyafford that I am licensed under provisions of Chapter 9 ISSUANCE DATE
afford
w (commencing with�Sdection 7000)of Division 3 of the Business and BLDG. ELECT. . PLG. MECH.
r m i Lice ss Co t II� 1¢enLi is in full for a effsC a ❑ .ts--ti
t o m License s II U Lia Numhe v I�Q
Q r w
Data 22 4 Contractor
x E - BUILDING PERMIT
o i U OWNER-BUILDER DECLARATION• RE R TO ORD INFORMATION
_W S u y I Aereby affirm thathI um exempt from the Contractor' cense misc. VALUATION - $(FT.
H w N.4 Law f the following reason.(Sec.7031.5,Business and ofessions pERMI SSUAN 10.00
my • Code: y city or county which requiresapermit toe 'tmcl,alter, '
"Q a, Q 2 Improve, emolish,or repair any structure,prior to issuance,also ELEC.CONTR. NO. ELEC.
i O u reghire3lh applicant for such permit to file a si d statement that TOTAL PERMIT O
L,$ he is license ursuar t to the provisions of th- onlrxctor's License
Fzi Law(Chapter (conrmencingwith Sectihn7 0)of DM,ion3oflhe
a Business and Pr essions Code)or that IT s exempt therefrom and QTY. R IT FEE
foo
K H$ the basis for thea pled exemption.An iolatino of Section 7031.5ST RIES YPE C STR.
byanyapplicamf apermitsubject he applicant to a civil penalty ALTER;D N&.VE -WATER (EA:) 5,00
of not more than fie undyed dol' s(5500).):
❑ I,as owner of a proper or my employees with wages as BACK 6heM PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensalio will the work,and the structure is not
intended or offered for (Sec. 7044, Business and Professions -7 DRAINS-FLOOR,ROOF,AREA,COND. 5.00 ' •pd
Cade:The Contractor's -ase Law does not apply to an owner of -
property who builds o alp ves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself re of ant
1' own a loyors,provided that such improve-
mentssrethroug- edwoffer fors provided
that such
building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 0
or imprhvemmm s sold within or year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will a the burden of pr mg that he did not build or im. BUILDING USE
proveforp phseofsale.). RES IND CON PB- Other
❑ I, owner of the property;an xclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
license 'ontractors to construct the feel(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Pr fevau ns Code:The Contractor's L 'ease Law does not apply -
to an owner of properly who builds or int oyes thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for suchprojects with a contractor(. licensed pursuant m
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1'amexemptunder Sea .BAP.C.for this WATER HEATER W/VENT - 6.00
reason
Owner Dale WATER SYSTEM 5.00 Op_
ACC.GATE ACC.FILE N0.
WORKERS'COMPENSATION D17CLARATION 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 thereof(Sec.3800,Lub.C.). -
Policy No. Co any
(] Cetlificd copy ler by famish Cd. r FIRE SPRINK ENERGY T-24
Z Z Certified op Is It It th city nspection division. MISC.- REFER TO ORD.
O Applicant _ - Y❑ N❑ v [3 No
f- va -"' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU CBRTIPICA E E CATIO TION F OM WORKERS' '
W �_ COMPI3NSATION INSURANCIi PLG.CONTR. LIC.NO. PLG. I1
CIL o (This se "n need not be completed if permit is for one TOTAL 3e.Ofl Y C1N[) Y E] NC)
Z hundred dollar 100)or Imo.) '
U O I certify that in a performance of a work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U. I- an
is issued,I shall employ an crson in any manner so as to
O become subject to elle ers' pensation Laws of California.
n Date - Apip ALTER OR ADD TO MECH. 5.00 ,JBUILDING
} rn NOTICE TO APPLICA ter making this Certificate of Cx- ,
r ? emption,you shout come subl ' to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of shot Code, you st foNhwilh Comply with FEE
fJ sucl ovisihns or this permit shall be dee revoked. AIR HANDLING UNIT(TO 10,OODC.F.M.) 4.00
CO ION LENDING AIR HANDLING UNIT(OVER IO,000GF.M.) 6.00 SEI SMIC FEE _
I hereby affirm that there ruction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the w or win yyy clout is issued(Sec. - MICR
3097,Civ.C.). \� HEATING UNIT TO 100,000 B.T.U.) 8.00
Lender's HEATING UNIT(OVER 100,000 B.T.U.19.50 EL6CTIS��
Lend ddress
1 certify that I have readthisapplicalion and state that the above VENTILATION FAN (SINGLE) '4.00
' information is correct. I agree to comply with all city and county ql, G 0, eb
BOILER-CUMPI3 H.P.or 100,000 B.T.U.) 6.0 Y•�
ordinances and stage laws relating to building construction, and Z •Q
hereby authorize representatives of this city to.enter upon the / BOILER-COMP (Over 100,00OBTU)SEEFEESCH. MECHANI L
above-mentioned property forinspection purposos.
ee to save; indemnify and keep harmless glee City of MISC.-{,S� REFER TO ORD. .(�(�
gainst liabilities,judg ts, costs and expenses which - PERMIT ISSUANCE 10.00 _� CONST.TAX
J.u6an way accrue sigains s d City in consequence of Ibehis per it. MECH.CONT. LIC.NO. MECH.D TOTALTOTAL / SAppBL m/ ac or )ate -�-D
OFFICE COPY I8o7 S�