5654 AV7LICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
;BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
aDIIDINL �� � APPLICATION & PERMIT � ^b 54
Aoovass
/O/y0'j -. Q.'L// .sAuS� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
rvAMEflncroR¢ ' ",,•,d. vu E-.
.8
PLAN CHECK VALIDATION
MG aEYUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No. LIGHTING FIXTURES 6.0017.00
CONTRACTOR
NTRA TORS
ADDRESS
APPLIANCES:RESIDENTIAL 4.00
PHONE PANELS - '5.00 DATE OF APPLICATION
OPHCHITECT SIGNS 6•DO PLAN CHECK FEE P.C.NO.
ENGINEEfl
LIC.NO AM SIGNS TRANS. 3.00
ARCH.OR ENG. s l_ A2�Y\ (l PERMIT VALIDATION
ADDRESS
'TZL((T FI U/(Z- SPECIAL CIRCUIT6.00
Ant C ci!.IIII G JAL zip! /29 EMP.METER OR POLE INS. 16.00
APPLICANT-6
ADORE .' , 307 c5. - { 1 `5'J. -tet MOTORS SEE FEE SCH. -
SERVICE CHANGE .10.00 tNM
oO LICENSED CONTRACTORS DECLARATION
x Z W I'hereby affrtn Ihal 1 am licensed under provision Of Chapter 9
< N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
n
i ProfessioCode,and my license is in full force and effect. El 11 ❑
c License GassLic.Number
H J Datc _ Contractor '
¢ u OWNER-BUILDER DECLARATION C 'b �) CINQf6
�' I- I:hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD gAFT.
. o 4 Law for the following reason.(Sec.7031.5,Businessand Professions 6.00
-0 PERMIT ISSUANCE
u> Code:Aoy Sly oncor rep wMch structure,
prmil o its issuance,
also
Z 0 Q Ira quires demolish,or for
su any SIinit ,ptlOr IO Ira ISaY3nee,aISO ELEC.CONTR. CIL.NO. ELEC. /s
o LL requires the applicant for such permit to file a signed slalement Thal TOTAL �If}f O f IRO PERMIT TO
a he is licensed pursuant to the provisions of the Contractor's License
i a u. Law lChipter9/commencing with Section 7000)of Division 3of the Condo. (.a units)
s x O Business and Professions Code)or that he is exempt therefrom and ��wYw7a7iA?.^Pi:UM81NGPERMIT FEE
L H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i 3� by an more
than
fora permit subjects $500).he licen((oa civil penally ALTER-DRAIN VENT-WATER (EA.) 4.00 2 5 N. Hr.
of nal more then five hundred dollars(5500).):
❑ I,as owner of the property,or my employms with wages as BACK FLOW PROTECT.DEV ICE 2.00 OCC.GROUP RES.UNITS
their sok 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. 4.00 H-1 8
It Code:The Contractor's License Law does not apply to an owner of
StI property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 6O FT.FLOOR AflEA TOTALACREAGE
himself or through his own employees,provided(hat such improve.
' .,irntsannotintendedorofferedforFile.If,however,thebuilding GAS-EA.SYSTEM-l1NC.40UTLETS 4.00 14,000
I improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
ouilder will have the burden of proving that he did not build or im-
XRES IND CON PS O.her
p ve for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
I as owner of the properly',am exclusively contracting with
li nsed contractors to construct the project(Sec. 7044.Business LAWN SPRINKLERS-1 INC 5 VIE. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of progeny who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 269-2-2
contracts for such projects with a contracroAs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec...B.&P.C.for(his WATER HEATER W/VENT 4.00 ]5]5
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
'WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, _ ZONING ENG.SITE N0.
Or a certificate of Workeri Compensation Insurance.or a certified
copy th.n of(Sec.3800,Lab.C.L J#A/ v�tlZ
Policy No. - Company
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z ZO ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. �.
_ Applicant v N V N
rn
'CERTIFICATEEXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
L -
L ( 'COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG. Y p N p Y 11 N EI
L � Thu redidn'need'not be completed if the permit is for oro• TOTAL
O hundred dollar,(SIOO)or less.) IMM.Ij' `:�r"`�L'- p,r; - ra's'+•
I certify that in the performance of the work for which this per _
-L I- ran is issued,1 shill not employ any person in an manner so as to - W V MECHAN1CAl.{{P.yyERMIT FEE „
Wbecome bice to the Workers'Compensation Laws of Califon' .. � �`:-4�vv�VtA«x�IdYS':ex�s 'a`F+�iA
UI /syLJJApplicant ALTER OR ADD TO MECH. v 4,00 BUILDINGS 1,260.5
>- y NOTICE TO APPLICANT: If,after making this Certificate of Ex
- Z emption;you'should become subject to the Wornia Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
Such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10AEOC.F.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,0MC.F.M.) 5.00 SEISMIC FEE 30.17
I hereby Affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance he work for which this permit is issued(Sec. MICROFILM
- 3097,Civ.C.l. �" �I HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's CC"L �'/✓t�'C`t_ HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's AddressAJ5NAl ,Z-py. y1 ELECTRIC
I carol 1 11)have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
mlormmion is correct I agree to comply with all city and county PLUMBING
"InanOes and slate laws relating lis building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
.cby authorize'representatives of this city to enter upon the BOILER-COMP(Ove,100,000 BTU)SEE FEE BCH. MECHANICAL
hove-mentioned property for inspection purposes.
4(We) agree to save, indemnify and keep harmless the City of misc.- REFER TO ORD.
Iperlino against liabilities,judgments,Costs and expenses which CONST.TAX
ly in any way accrue a•ainsl said ily in consequence of the PERMIT ISSUANCE 3.00 -
ing his pe L MECH.CONT. LIC.NO. MECH. `•,, '. iSsa$
TOTAL TOT,AI. 1 a 290.67
fimurcof ApplicantlContmctor ale
OFFICE COPY . .