7050 APPLICANT TO FILL IN;INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
aUILDINO APPLICATION & PERMIT O O
ADDRESS pp
IOIOI K • bC ArNZA I�L�ID BUILDING-ELECTRICAL-PLUMBING-Mf,ECHhyA�iNICAL
Y DNAME Rs�N SS E1L Dr,T%�`T211f�.1.+'^LEf.•RIC PERMIT 2 liP( 4N' WIFEE" PLAN CHECK VALIDATION
PHONE > vas, k1R..an +-6',E ,r, ` ;1«•;.t ". LtC
r, NAMERAcroRs UTLETS-SWITCHES-RECEP 5.00/100
J ' THE- K0L_L C_0 ' LIC NO LIGHTING FIXTURES 5.00/1.00
LNS CONTRACTOR'S
} X ADDRESS fICTcjI t4 , r/2 / S�I"-' PPLIANCES-RESIDENTIAL 4.00
Q \ AN -30srz__ PHONE 60_ O0 PANELS 5.00 DATE OF APPLICATION
ARCHITECT TAMi:< F_ Lica VSs C7 C SIGNS BOD PLAN CHECK FEE P.C.NO.
OR l
MR
ER
a � - L.C.No. SIGNS TRANS. 3.00
ARCH.OR ENG' SPECIALCIRCUIT S.00 PERMIT VALIDATION
ADDR`I 1� ZIP EMP.METER OR POLE INS. 15.00 C
ADDREssTsf��Y STI(�-f^ %GNAN CIj-(,. MOTORS SEE FEE SCH. J
0 ) ot-1/YDIsore CI• 5/N 17DN5 SERVICE CHANGE 10.00 /
A
W o o LICENSED CONTRACTORS DECLARATION
<u u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
As<n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. I PLG. MECH.
i Professions Code.pnd m licen is in full(o ce and of(ecl.
G i w- License Class C-Clu Lia Number j+' F-1 El
w� Date I�)h-gs ConInclor L&
C__
HN/C/dam BUILDING:PERMIT
Q se¢¢ OWNER-BUILDER DECLARA IO
E. O a u i ;,INFORMAT10 '
X ;u m I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION u O Q Law for the following reason.(Sec.7031.5,Business and Professions SIFT'
_ g PERMIT ISSUANCE 6.00
E �> E Code: e.y coolish coup pair any structure permil(oconsuanLalmq
Z 5 Q O implore.demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
m¢ requires the applicant for such permit to file a>igned statement that TOTAL PFRMI TO
whe is licensed pursuant to the provisions of the Contractor's License
-i Law(Cha ter 9(commencin with Section 7000)of Division 3 of the °v sfap :1.`'fi L`r Gr arc"• `dc Kar+
Ei o business and Professions Code)or that he is exempt therefrom and QTiiVrW1 Y.yvGs.?aPL`UMBING'PERMITa �11+,°LJ' a N PEEF„(.
e I-m the basis for the alleged exemption.Any violation ofSection 70315 C.Y'{r'x arhv`Lhf!` +aro �"s.."s,,,'tl'v v-may.,., 4Y5ro of ii ,: � STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penally ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(E500)J:
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP REB.UNITS
Iheir 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. 4.00
Code:The Contractor's License Law don not apply to an owner of
Property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SOFT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.4 OUTLETS 4,00
mems are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS•EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving That he did not build or im- RES IND CON PB Omar
prove for purpose of sale.(. INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,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:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I nm exempt under Sec.-.BAP.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
RK�ERRS'CENSA N DECLARATION WATER TREATING EQUIP. 4.00
h%? rl.le
of Consent to self-insure, ZONING ENG.SITE NO.
a certificate of Workers'Compensation Insurance,or a certified
,J cap) eof(Sec.3800,I-A.C.1'R y I �F ORO-=
Pohcp No.-ComPany
❑ C I m copy iS he by furnished FIRE SPRINK ENERGY T$4
Z x tent copy ' ( witn to cit speclo�i7�is4 MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
O Applicant /- V N Y N
~ vaPERMIT ISSUANCE 6.00 FLOOD 20NE A.L.U.C.
CERTIFICATE OF EXEMPTION FROM WORKERS'
LU LU OCOMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. ❑ ❑ ❑ ❑
(This section need not be completed if the permit is for one TOTAL v N Y N
� Z hundred dollars(S100)orless.l ',>r'+',.w s, E �:rlt 3 T'Q 4aF '-sy - s'sgw 3f,�•iv -' '•..� 7
U O 1 certify that in the perfoonence of the work for which this Per O ,r;'.MECHANICAL PERMIT''' >' 4rFEEm, Via','1�:iSsUPEESl1Mt�ARVy �s'•y
LL H mil is issued,I shall not employ any person in any manner so as Io A, • ^,T,i-_s_ t a"u.i.,5`A(1C Sy b A -
1 U become subject to the Workers'Compensation Lawsof California. ir�aIt
O w Dale Applicant BUILDING
a ALTER OR ADD TO MEC .S y� f 4.00 c.l.
} 0 NOTICE TO APPLICANT: IL after making this Certificate of Ex.
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 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 10MOC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender s IN H EATING UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state Paws relating to building construction. and BOILER-COMPI3 H.P.Or 100,0008.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IO.rIOO,DDOSTU)SEEFEESCH. MECHANICAL e.?3
' above-mentioned property for inspection purposes,
4WeI-agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
rerun- against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
sa in any way accrue against said City in consequence of the
a(this pe it., ECH.CONT LID.NO. TOTAL 00 7 Y A'k•7 Tk t ro
F,�- I-1o_gr, DL�cRlke 2rj38`19 �'� %TOTALi;.o.c
roam of Applican Co tactor Date
, .:
OFFICE COPY