18872 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT.PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER .
BUILDING /Yl APPLICATION & PERMIT I�
AD E5a
UILDING-ELECTRICAL-PLUMBING-MECHANICAL a ' I
OWNER'S ��--VVPLAN CHECK VALIDATION
NWA aS,3 -Ctod-U OTY. ELECTRIC PERMIT FEE
PHONE
CONTRACTOR'S
rvnm OUTLETS 10.00/1.00
Its uallo ' LIGHTING FIXTURES 10.00/1.00
CONTRACTORS ^ ^� '��/� APPLIANCES-RESIDENTIAL 4.00 -
CONTRA Ol`NX1/`-11 q/ -
PR E PANELS 10.00 DATE OF APPLICATION -
AOR
RCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
.LIC.No. SIGNS TRANS. 3.00
AARC
OOHESS ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS
AMOTORS SEE FEE SCH.
ORESERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION 'ITl✓"� r
a U U I hereby affirm that I am licensed under provisions of Chapter 9 P SDANCE DATE
N z w (commencing with Section 7000)of Division 3 of the Business and
n 1
APR
n BLDG. ELECT. PLG. MECH.
H i Professions Code,and my license is in full force and effect. ❑2 License Class
O . ❑ , �• ❑
o m H Date Contract., pp���E4
y
id MIV, Cu BUILDING PERMIT
* a,w a OWNER-BUILDER DECLARATION INFORMATION
a 0 a `-' MISC.- REFER TO ORD
X g u w I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
F a w j Law for the following reason.(Sec.7031.5,Business and Prul'useions pERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
<2O improve,demolish,or repair any structure,prior hs its issuance,also ELEC.CONTR. LIF NO. $LEC.
-c u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m m he is licensed pursuant to the provisions of the Contractor's License
FZ > Law(Chapter9(commencing with Suction 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom andQTY. PLUMBING PERMIT FEE
H m the basis for Ilse alleged exemption.Any violation Of Sectiom 7031.$ S ORI -TYPE CONSTR.
by any applicant for a permit subjects the applicant toaclvllpenalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,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 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided Ihal such improve-
meats are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 - ,BUILDING USE
builder will have the burden of moving that hu did not buil)or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting wilh ❑ ❑ ❑ ❑ ❑
licensed contractors to construe( 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
contracts hor such projects with a coidmctor(s)licensed pursuant to
the Contmctols License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCELNO.
❑ I am exempt under Sec.-,RAP.C.for this
WATER HEATER W/VENT •6:00 a, -
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS;COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
.1 hereby affirm that I have a certificate of consent to sal Ginsure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified _
copy thereof(Sec.3900,Lah.C.).-
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T24
Z Z -❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD, y N❑ y [:] N[]O Applicant
F-
Lu y CIiRTII9CPERMIT ISSUANCE 1QB0 �w FLOOD ZONE A.LU.C.
'
W CCOMPEOMPEEXEMPTION FROM WORKERS'
INSURANCEPLG.CONTR. LIC.NO. DLG. x'
0' D (This section need not he completed if the permit is for one TOTAL ) r 00 y❑ N[J V [:] NE]
0 Z hundred dollms($100)or less.)
U O I certify that in the performance of the work for which this Per. OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL l- mil is issued, I shall not employ any person in any manner so as to
U becomesubject to the Workers'Compensation Laws of California.
0 u Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE 10 APPLICANT: If,after making this Certificate of Ex-
F ? enspthem,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 UNIT(TO 10MCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.)'6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name
Lender's NAddress HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
am
1 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 .1 this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Liver mo against liabilities,judgment S, costs mW expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
r ting This permit
MECH.CONT. LIC.NO. MECH.
l V . TOTAL TOTAL I
[ureo pplicant/Contr t Date v/v
OFFICE COPY