13566 - APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMB
BUILDING APPLICATION & PERMIT
AO13566
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JJO 1 zwE BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'5 dd / PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
?1141,11;c-
11 PHONE
NAMERACTofl's t UTLETS-SWITCHES-RECEP 10,0011.00
E ifjC LIC.No.% U-9 LIGHTING FIXTURES 10.00/1.00
,ONTRACTOR's eyv
PPLIANCES-RESIDENTIAL 4,00
ADDREss
00 lrtvB�e,� HONE PANELS 10.00 DATE OF APPLICATION
ORRCHrtECT // 1 / 92 PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER V\i/1 7 `C
LIC.NO. SIGNS TRANS. 3.00 _
ADDRESS ENG. PERMIT VALIDATION
ADDREss SPECIAL CIRCUIT 5.00 -�-)
ZIP TEMP.METER OR POLE INS. 20.00 r�/Ir
APPLICANT'S ADDRESSMOTORS SEE FEE SCH.SERVICE CHANGE 20.00
torjta
X o LICENSED CON"TRACTORS DECLARATION
v I hereby,affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
azw
(commencing with Section 7000)of Division 3 of the Business andBLDG. ELECT. I PLG. MECH.
Ni Professions Co a license is in full fon
'0.- License Class Lic.Number ❑ ❑ ❑
o C3 �J.e) Contractor
U ' / BUILDING PERMIT
Ic tc w < OWNER-BUILDER DELL A 10 INFORMATION
noMU MISC.- REFER TO ORD
X ; N 1 hereby affirm that I am exempt from the Comractor's License VALUATION $/FT.
cocoon Law for the following reason. 703 L5,Business and Professions PERMIT ISSUANCE 10.00
r a a Code:Any city or county which requires a permit to construct,alter,
2 ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
It
- 0, requires the applicant for such permit m file a signed statement that TOTAL R TO
w $m he is licensed pursuant to the provisions of the Contractor's License
rz>0 Law(Chapter 9(commencing with Section 7000)of Division3 ofihe
a Business and Professions Code)or that he is exempt therefrom and QTY. . PLUMBING PERMIT FEE
¢ r0 the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).1:
❑ 1,as owner of the property,or my employees with wages 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 5,110 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve.
meats are 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 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the properly,am exclusively contracting 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 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
contractsfor such projects with a contractoHs)licensed pursuant m
thContContractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the
❑ lam exempt under Sec..,BAP.C.for this WATER HEATER WIVENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPF•NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have u certificate of consent to Self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company -
Q ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. y❑ N❑ y C] N[:]O Applicant
S N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU ' COMPENSATION INSURANCE PLG.CONTR. LIC,NO. PLG.
a O (This section need not be completed if the permit is for one TOTAL y❑ N❑ v ❑ N❑
LD Z hundred doll..IS 100)or less.)
U O 1 certify that in the performyncey the workfeywhich this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued.I shall not emplo erso " rGQy4 manner so as to
U beco ubje t to a Workeri ansa' uw (California.
0 a Date PPlicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTI A (CANT: ter maki t1 s Cenifica h lix-
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNITr(TO-10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING U-IT(OVER IQO170C.RM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITCH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
�
3097,Civ.C.). t HEATING U 144(TO 100,000 B.T.U.) 8.00
Lender's Name H EATING UNIT(OVER,I,OO,OODIB.T.U.19.50 ELECTRIC
Lender's Address
1 certify that I have read this application and state(hat the above VENTILATIONtF.AN'(SI NGLE) 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 I3 H.Por 100,000 B.T.U.) 6.00
hereby authorize representatives of this city (o enter upon the BOILER-COMP IOVer 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We
to Save, indemnify and p harmless [he City of MISC.-' REFER TO ORD.
Cupenst I' bi kies,judgmen tis and expenses which OCONST.TAX
may iay ec a ainstsa' rtyin consequence of le PERMIT ISSUANCE10.00grant' p MECH.CONT. LIC.NO. MECH,
TOTAL U0- TOTALyo-
nre0 (cantJCcmt,Act Date -2( -
OFFICE COPY