8948 APPLICANT TO"FILL•IN INFORMATION WITHIN RED LINES - USE BALL POINT.PEN ONLY
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BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
OU"LLING APPLICATION & PERMIT
ADDRESS 8948tO4'o\ Cas-hr� N-4 P_
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
NAME ' PLAN CHECK VALIDATION
-2c,5
EA, QTY. ELECTRIC PERMIT FEE
N1. &oldre�an PHONE'2S5=
CONTRACTOR s1 �• Cep UTLETS-SWITCHES-RECEP 10.00/1.00
T8 \e J �IIL Llc.No. 4Z3 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS +5 1 APPLIANCES-RESIDENTIAL 4.00
L+
s.
n'IQ,TII&A. '� PRONES 3PANELS 2•p 10.00 /0 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
• LIC.NO. ISIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG ,' I SPECIAL CIRCUIT 5.00 _ PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESSMOTORS SPJNIMH,
SERVICE CHANGE - 20.00 t,/Jl.�""
H¢O O LICENSED CONTRACTORS DECLARATION - TEMP.POLE /����
<i w 1 hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANC DATE
(commencing with Section 7000)of Division 3 of the Business and Q(LI 0
. Ii+ ¢s BLDG. ELECT. PLG. MECH.
F N z Professions Code,an.Wlicense is in full farce flet[.
Qz ut o, License Class G Lie.Number i El I I�-�yrl �I�yl�
,A r Date 4-Z -Contractor ^� T
Q y
id
¢ ¢ a OWNER-BUILDER DECLARATION BUILDING PERMIT
a u INFORMATION
w0'c I- I hereby affirm that 1 am exempt from the Contractor's License MISC. REFER TO ORD
Law for the following reason(See.7031.5,Bc,mm,sand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter, - -Q
Q Q Q Improve,demolish,or repair any structure,prior to its Issuance,also ELEC.CONTR. LIC.NQ ELEC.
i Lm, 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 /
w Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe &L,--r-77 MGT=`r-//71.
5 ¢ o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o -the basis for the alleged exemption.Any violation of Section 7031.5 STORIES I TYPE CONSTR.
i; 5 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wage's as BACK FLOW PROTECT.DEVICE 4,00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5,00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsare not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im BUILDING USE
RE$ IND CON PB Omer
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 . 1:1 El 11 1:1 1:1❑ I,as owner of the property,am exclusively contacting 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 Contractors 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(a)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy ther of(Sec. 00,Lab.C.l. r.` .� ^,
Policy,N Nin �Tfn ltAl VN
Q ❑ Certified copy is hereby furnished. - FIRE SPRINK ENERGY T-24
_Z Z �+ Certifle o is led With tW ci ins tiou division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
Applicant ti E _A\C V N V N
~ rn
UJ - CIiRTI FI
EXEMPTION FROM WORKERS' - FLOOD ZONE A.L.U.C.
W -COMPENSATION PERMIT ISSUANCE 10.00 INSURANCE PLG.CONTR. LIC.NO. PLG.
0- Z( This section need not be completed if the permit is for one TOTAL Y❑ N❑ N
Y❑ ❑
hundred dollars IS 100)or less.) '
0 O 1 certify that in the performance of the work for which this per- p7y MECHANICAL PERMIT FEE FEE SUMMARY
t
LL mit is issued,I�shall not employ any person in any manner so as to -'-t•'
O become subject to the Workers'Compensation Laws of Califoa. V
0 y rniDate Applicant - ALTER OR ADD TO 5,00 BUILDING
} rn NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(T 1 C.x:M.1 • 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNI 0,000 C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH Q 5.00
the performance of the work for which this permit is issued(Sec, 17 MICROFILM
3097,Civ.C.). I HEATING UNIT(TO ,OOB.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I 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 PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the g01LER-COMP (Over 1 0,00 BTU)SEE FEE SCH. MECHANICAL p2 + �N
above-mentioned property for inspection purposes.
`y
(We) agree to save, indemnify and keep harmless the City of MISC.- A TO ORD.
Cuper' o ainsl liabilit ,ju mems, costs and expenses which PERMIT ISSUANCE • 10.00 /0 CONST.TAX
may w ace - mst aid City in consequence of the
gra t Pe i MECH.CONT. LIC.NO,C-10 MECH.
�' Z TOTAL o_�4 TOTAL QB
Z'_ G EVJx-L
Signature of A pplman[/Contractor Datecc
4
OFFICE COPY