6127 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON PERMIT NUMBER
DU LDINc Iy_-� APPLICATION & PERMIT
ADORES BUILDING
02 - OZ.3 'J D.Is,l�y't.. pnU-� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
6127
RS �nV il� PLAN CHECK VALIDATION
NAME )� T L,Jh Cc�l v \ DTY. ELECTRIC PERMIT FEE
PHONE
cDN5';
E l� P 4h�, /7 UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
LIc.No. LIGHTING FIXTURES 5.00/1.00
CONTRACT Rs (s APPLIANCES-RESIDENTIAL 4.00
ARE55
5-35--� ACQ ��PMONE jO 'u PANELS 5.0O DATE OF APPLICATION
ARCHITECT SIGNS 6,00 PLAN CHECK FEE P.C.NO.
on
ENGINEER
LIC.Na. SIGNS TRANS. 3,00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
ESS
10.00
�00 LICENSED CON IRACI'ORS DECLARAI ION _ _ •(
¢ U u I hereby affirm that I am licensed under provisions of Chapter ISSUANCE DATE
a,G e_ (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r y i I'ml'es,ono Code and my license is in full force aqd effe t ❑
zau, License Class_ - I,ic.Number_ ❑ ❑ ❑
g r w UateConrmcmr - r
a Y s BUILDING PERMIT
¢ a w ¢ OWNER.BUILDER DECLARATION INFORMATION'
D REFER TO ORD
w LL N I hereby alHnn That I um exempt from the Contractor's License MISC.- VALUATION $/FT.
0 j Law for the following reason.(Sea]031.5.Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or vunty which requires permit to construct,alter,
¢ ¢ 0 improve,demolish,or repair any Structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License
r- zi Law(Chapter 9(commencingwlih Section 7000)of Division 3afthe
4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H Do the basis for the alleged cxempliou.Any violation of Section 703 L5 STORIES TYPE CONSTR.
aim by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of nor more than five hundred dollms(S500.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do[lie work,and the structure Is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00 -
Code:The Cm ametor's License Law does not apply to an owner of
property with builds or improves thereon,and who docs such work 30 FIXTURES-PER TRAP 4.00 ID,yrtrt
D SO.FT.FLOOR AREA TOTAL ACREAGE
„imsell'or through his own employees.provided that such improve- .
meats are nor intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
mplhvmnenl is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that lie did not build or im- RES IND CON PB Other
pfove for purpos,of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the propurry,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I lie 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
nitructS for such projects with it contracloris)licensed pursuant to - ��'•+'x �pJ
the Contractor's Licenm Law. 00 SEWER-SANITARY-S EA.200ft/8.00 .0 TRACT NO. PARCEL NO.
❑ lam uxcnspt under Scc. ,B.&P.C.I'or this WATER HEATER W/VENT 4.00 0D
neastill /
Owner Date WATER SYSTEM 4 4.00 -OD ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, e p 4.00
I hereby alhr111 ilial I have u certificate ar.osent to sol Flnshre, niti of fs yI lit ZONING
or a ecrlilicale of Workers'Compensation Insurance,or a certified Cu ENG.SITE NO.
copy thereof I See.3800,Lab C.I.
Policy Nn. Company_�D0.t I
Q Certified copy is hereby f hrmshodSP$r'��Igrj FIRE SPRINK ENERGY T-24
Z Z ❑ anRifieJ aryy is file. J,gilh t. city inspection divivoa MISC.- REFER TO ORD. Y❑ NEI Y ❑ N❑
O Applicant-
2 T CERTIpIC\I'1:10171 XI'MPTION FROM WORKERS' PERMIT ISSUANCE 6.00 &a.ISO FLOOD ZONE A.L.U.C.
UJ > COMPENSATION INSURANCE PLG.CONTH. LIC_NO. TOTAL/�O p0 ❑ ❑ ❑ ❑
V N Y N
tx Q ('Phis Section need not he completed if(he permit is for one
Z hundred dollars IS 100)or less.) --
U'x0 I certify that in the performance of tire work for which this per- QTY. MECHANICAL PERMIT FEE 'FEE;SUMMARV�"t f{`
mit is issued.I shall nor employ any person in any manner so as to
O W become suhjecl R,(lie Workers'Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECN, q,Op BUILDING
>_ N`r NOTICE '1'O APPLICANT': If,after making this Certificate of Ex-
F, Z\ enlptlun,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
s provisions of tiro I,almr Cade, you must forthwith comply wi(h FEE
U such provisions or this permit slmll be deemed( EO
evoked. AIR HANDLING UNIT(TO 1QOGF.M.) 3.00
CONST RUCI ION LENDING AGENCY AIR HANDLING UNIT(OVER l0PWC.EM,) 5.00 SEISMIC FEE
I hereby allirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perlornipncc or the work liar which this permit is Issued(Sec. MICROFILM
3097,Civ.C.). /lYftixr. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name - KnnSnSP. HEATING UNIT(OVER 100,000B.T.U.)7.50 ELECTRIC
Lender's Addre' -'1L 121-t-cY ara�fY'^ Vl n '.-
I certify that I have read his application and state the(the above VENTILATION FAN (SINGLE) 3.00
information is correc(. I agree to comply with all city and cobove PLUMBING 0
ordinances and slate laws relating to building construction, and BOILER-ODIvP 13 H.P.of 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the g01 LER-COMP loser 100,000 BTU)SEE FEE SCH. MECHANICAL
above memioned property for inspection Purposes.
(We) agree W save, indemnify and keep broadcast the City of MISC.- REFER TO ORD.
Cancrtieo against liabilities,judgments, costs and expenses which CONST.TAX
may in any way areme against said City in consequence of the PERMIT ISSUANCE 3.00
granting of this Permit MECH.CONT. LIC.NO. METH. TOTAL
-
TOTAL
Signatur.of ApplicantlContraclorl I id Date
I OFFICECOPY